RU2790238C1 - Method for installation of a venous port system - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology, and can be used to install a venous port system. After vein puncture, a metal J-shaped conductor 80 cm or more long is inserted through the lumen of the needle. A bougie with an introducer is inserted along the guidewire into the lumen of the vessel, then the bougie is removed from the introducer, while the introducer and guide wire should remain in the lumen of the vein. Then, the catheter is inserted into the vein along the string through the introducer, when the mark of 50-55 cm on the catheter is reached, the string is removed from the catheter, the catheter is washed with saline and fluoroscopy is performed to visualize the location of the catheter tip in the superior vena cava. Then the introducer is removed from the vein, after catheterization of the main vein and the superior vena cava, a pocket is formed in the region of the upper third of the forearm. Departing from the elbow crease by 2-3 cm down, moreover, the size of the incision is made 0.5-1.0 cm larger than the diameter of the implanted port, after cutting the skin with a clamp and a hook, the pancreas tissues are pushed apart in a blunt way and a pocket is formed. With the help of a metal conductor, a tunnel is formed between the subcutaneous fat and the superficial fascia of the shoulder and forearm from the vein puncture site to the pocket. The catheter is passed through the tunnel, the tip of the catheter is brought out into the pocket and the coupling is put on it, the catheter is cut, put on the port cannula and fixed in this position by the coupling. The port is then dipped into the pocket and sutured to ensure a stable position.

EFFECT: method provides increased efficiency of administration of medicinal substances during course chemotherapy in patients with developed subcutaneous fat and high BMI, absence of scars and skin defects in the décolleté area, absence of complications in the form of hemothorax and pneumothorax due to methods for performing implantation of the venous port system.

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Description

The invention relates to medicine, namely to anesthesiology, and can be used when installing a venous port system.

A known method of installing a venous port system. The advent of the Totally Implantable Venous Access Device (TIVAD) in 1982 enabled physicians to provide long-term vascular access to patients in need. Today, the main group of people who most often undergo implantation of the venous port system are cancer patients undergoing long-term chemotherapy courses either as monotherapy or as part of combination therapy along with surgical treatment. In addition to chemotherapy, the port system allows such patients to perform multiple blood sampling for laboratory tests, as well as, if necessary, infusion, transfusion or nutritional therapy [1-Egiev V.N., Shchetinin V.V., Trofimenko Yu. G. Fully implantable systems in medicine. - M., 2004. - 60 p.]. This method is accepted as analog.

The use of central venous access allows long-term infusions and repeated administrations of chemotherapy drugs. The widespread use of port systems in oncology is explained by the fact that frequent catheterization of peripheral veins is accompanied by the development of a number of complications: chemical phlebitis or phlebothrombosis due to their small diameter, low blood flow velocity; catheter-associated infections due to the short path for bacteria from the contaminated skin surface to the lumen of the vessel; soft tissue necrosis - in case of extravasation of the drug. The use of central venous access avoids these problems. Therefore, today many experts recognize the fact that the implementation of long-term infusions and repeated injections of chemotherapeutic drugs is possible only through the central venous access.

However, frequent central venous catheterization is also associated with the risk of developing severe complications both during catheterizations themselves and during catheter operation. The most formidable complications during the installation and use of CVCs are: pneumothorax, hemothorax, catheter-associated infection, sepsis and air embolism. In addition, the presence of CVC in a patient inevitably causes discomfort due to “protruding tubes”, creates difficulties in performing hygiene procedures and seriously limits physical activity. Implantation of a port system makes it possible to practically reduce the risks of developing these complications to zero. The main reason for this is the fact that the port is not subject to any external influences, since the system is placed under the skin, and the catheter is installed in a large diameter vein. In addition, an important advantage of this system is the psychological comfort of the patient, due to the absence of pain from multiple (often not on the first attempt) punctures of peripheral or central veins. [2- Li G, Zhang Y, Ma H, Zheng J. Arm port vs chest port: a systematic review and meta-analysis. Cancer Management Res. 2019 Jul 3;11:6099-6112]. This method is adopted as a prototype. The most formidable complications in the installation and use of CVC are: pneumothorax, hemothorax, catheter-associated infection, sepsis and air embolism.

The goal is to increase the effectiveness of the administration of drugs during the course of chemotherapy.

The technical result is achieved by the fact that after vein puncture, a metal J-shaped conductor 80 cm or more long is inserted through the lumen of the needle, a bougie with an introducer is inserted through the conductor into the lumen of the vessel, then the bougie is removed from the introducer, while the introducer and the conductor string must remain in the lumen of the vein, then the catheter is inserted into the vein along the string through the introducer, when the catheter reaches a mark of 50 cm - 55 cm, the string is removed from the catheter, the catheter is washed with saline and fluoroscopy is performed to visualize the location of the catheter tip in the superior vena cava, then the introducer is removed from the vein, after performing catheterization of the main vein and the superior vena cava, they begin to form a pocket in the region of the upper third of the forearm, retreating from the elbow crease by 2-3 cm down, moreover, the size of the incision is made 0.5-1.0 cm larger than the diameter of the implanted port, after skin incisions using a clamp and a hook in a blunt way push the tissues of the subcutaneous fat (SAT) and form a pocket, with the help of a metal conductor, a tunnel is formed between the subcutaneous fat and the superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the tip of the catheter is brought into the pocket and a coupling is put on it, the catheter is cut, put on port cannula and fixed in this position with a coupling, then the port is immersed in the pocket and sutured to ensure a stable position.

The method is implemented as follows.

Carry out standard preparation of the operating field in accordance with the internal protocol of the institution. The non-dominant arm of the patient is treated from the base of the hand to the armpit entirely from all sides. After processing the surgical field and wrapping the operation site with sterile linen, venipuncture v. basilica, which is performed under ultrasound guidance. Ultrasound screening v. Basilica is carried out along its entire length to exclude its thrombosis and features of the anatomical structure. At the time of puncture, a venous tourniquet is used, which is placed in the upper third of the shoulder before processing the surgical field. The use of a tourniquet allows for good blood supply to the vein and increases the size of the vein.

Puncture v. basilica is performed in the lower third of the shoulder. Before vein puncture, local anesthesia of the skin and tissues is performed with a 2% lidocaine solution with a small diameter needle (22-24G). Depending on the position of the ultrasound probe in relation to the course of the vein, vein puncture is performed either with visualization of the needle throughout (in plane), or with visualization of only the tip of the needle (out of plane). When the vein has been successfully punctured, a metal J-guide 80 cm or more in length is passed through the lumen of the needle.

Having installed the conductor in the vein, ultrasonic control of the position of the conductor in the vein and X-ray control are carried out to confirm its position in the superior vena cava. Then, at the exit point of the conductor, they are incised with a scalpel. A bougie with an introducer is inserted into the lumen of the vessel along the guidewire. The bougie is removed from the introducer, while the introducer and guide wire should remain in the lumen of the vein. Then, along the string through the introducer, a catheter is inserted into the vein. Upon reaching the mark of 50 cm - 55 cm on the catheter, the string is removed from the catheter. The catheter is washed with Sol.NaCl 0.9%. Then, fluoroscopy of the location of the catheter tip in the superior vena cava is performed, and only then the sheath is removed from the vein.

After catheterization v. Basilica and superior vena cava, begin to form a pocket in the region of the upper third of the forearm, stepping back from the elbow crease by 2-3 cm down, moreover, the size of the incision is made 0.5-1.0 cm larger than the diameter of the implanted port, after dissection of the skin with using a clamp and a hook, the pancreas tissues are bluntly pushed apart and a pocket is formed, with the help of a metal conductor, a tunnel is formed between the subcutaneous fat and the superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the catheter tip is brought into the pocket and onto it the connector is put on, the catheter is cut, put on the cannula of the port and fixed in this position with the connector, then the port is immersed in the pocket and sutured to ensure a stable position. After that, the wound is sutured in layers with absorbable suture material.

The advantages of installing a port system in the cubital fossa: reducing the frequency of formation of unwanted loops and bends along the catheter while maintaining an active lifestyle of a cancer patient, ease of use of the port system in patients with developed subcutaneous fat and high BMI, the absence of scars and skin defects in decollete zone, absence of complications in the form of hemothorax and pneumothorax.

The method is confirmed by the following examples

Example #1. Patient R., aged 57

Main diagnosis: C18.6 Cancer of the descending colon pT4aN0M1b, stage IVB, class II. group. MSS, RAS, BRAF-wt. Obstructive left-sided hemicolectomy from 07.11.2019. 10 courses of XT 1 line in the FOLFOX + cetuximab regimen, 7 courses of XT maintenance in the De Gramont regimen of cetuximab. Reconstructive and restorative operation to restore the patency of the colon with the imposition of a manual transverse sigmoanastomosis end-to-side. Progression, increase in the size of the mts in the liver, in the lateral pedicle of the left adrenal gland., pT4aN0M1b, stage IVB, class II. group

Operation: Implantation of the venous port system

Carry out standard preparation of the operating field in accordance with the internal protocol of the institution. The non-dominant hand of the patient is treated from the base of the hand to the armpit entirely from all sides. After processing the surgical field and wrapping the operation site with sterile linen, venipuncture v. basilica, which is performed under ultrasound guidance. Ultrasound screening v. Basilica is carried out along its entire length to exclude its thrombosis and features of the anatomical structure. At the time of puncture, a venous tourniquet is used, which is placed in the upper third of the shoulder before processing the surgical field. The use of a tourniquet allows for good blood supply to the vein and increases the size of the vein.

Puncture v. basilica is performed in the middle third of the shoulder. Before vein puncture, local anesthesia of the skin and tissues is performed with a 2% lidocaine solution using a 22G needle. Depending on the position of the ultrasound probe in relation to the course of the vein, vein puncture is performed with visualization of the needle throughout. When the vein is successfully punctured, a metal J-shaped conductor 80 cm long is inserted through the lumen of the needle, a bougie with an introducer is inserted through the conductor into the lumen of the vessel, then the bougie bougie is removed from the introducer, while the introducer and the conductor string should remain in the lumen of the vein, then the catheter is inserted into the vein through the introducer, when the catheter reaches a mark of 50 cm, the catheter is removed from the catheter, the catheter is washed with saline and fluoroscopy is performed to visualize the location of the catheter tip in the superior vena cava, then the introducer is removed from the vein, after catheterization of the main vein and superior vena cava the veins begin to form a pocket in the region of the upper third of the forearm, stepping back from the elbow crease by 2 cm down, and the size of the incision is made 0.5 cm larger than the diameter of the implanted port; pocket, with the help of a metal conductor form a tunnel m through the subcutaneous fat and superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the tip of the catheter is brought out into the pocket and a coupling is put on it, the catheter is cut, put on the port cannula and fixed in this position with a coupling, the port is then dipped into the pocket and sutured to ensure a stable position. After that, the wound is sutured in layers with absorbable suture material.

Example #2. Patient G. 49 years old

Main diagnosis: С18.7 Cancer of the splenic flexure of the colon pT4N1M0, st. IIIB (KRAS, NRAS, BRAF - WT). Comprehensive treatment in 2013-2020. Progression: Appearance of new metastatic foci in the liver. 1 course of chemotherapy according to the FOLFIRI scheme with dose reduction by 50%. 4 courses of chemotherapy according to the scheme: Irinotecan + Aflibercept pT4aN1aM0, stage IIIB, IV class.

Operation: Implantation of the venous port system

Carry out standard preparation of the operating field in accordance with the internal protocol of the institution. The non-dominant arm of the patient is treated from the base of the hand to the armpit entirely from all sides. After processing the surgical field and wrapping the operation site with sterile linen, venipuncture v. basilica, which is performed under ultrasound guidance. Ultrasound screening v. Basilica is carried out along its entire length to exclude its thrombosis and features of the anatomical structure. At the time of puncture, a venous tourniquet is used, which is placed in the upper third of the shoulder before processing the surgical field. The use of a tourniquet allows for good blood supply to the vein and increases the size of the vein.

Puncture v. basilica is performed in the middle third of the shoulder. Before vein puncture, local anesthesia of the skin and tissues is performed with a 2% lidocaine solution with a small diameter 24G needle. Depending on the position of the ultrasound probe relative to the course of the vein, vein puncture is performed with visualization of only the tip of the needle (out of plane). When the vein is successfully punctured, a metal J-guide 84 cm long is passed through the lumen of the needle.

Having installed the conductor in the vein, ultrasonic control of the position of the conductor in the vein and X-ray control are carried out to confirm its position in the superior vena cava. Then, at the exit site of the conductor, the skin is incised with a scalpel. A bougie with an introducer is inserted into the lumen of the vessel along the guidewire. The bougie is removed from the introducer, while the introducer and guide wire should remain in the lumen of the vein. Then, along the string through the introducer, a catheter is inserted into the vein. Upon reaching the mark of 55 cm on the catheter, the string is removed from the catheter. The catheter is washed with Sol.NaCl 0.9%. Then, fluoroscopy of the location of the catheter tip in the superior vena cava is performed, and only then the sheath is removed from the vein.

After performing catheterization of the main vein and the superior vena cava, a pocket is formed in the area of the upper third of the forearm, retreating from the elbow crease by 3 cm down, moreover, the size of the incision is made 1.0 cm larger than the diameter of the implanted port, after cutting the skin with a clamp and hooks bluntly push the pancreas tissues apart and form a pocket, with the help of a metal conductor a tunnel is formed between the subcutaneous fat and superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the tip of the catheter is brought into the pocket and a coupling is put on it , the catheter is cut, put on the cannula of the port and fixed in this position with a coupling, then the port is immersed in the pocket and sutured to ensure a stable position.

. After that, the wound is sutured in layers with absorbable suture material.

Example #3. T. 67 years old

Main diagnosis: C25.0 Tumor of the head of the pancreas cT4N1M1(Hep). 5 courses of XT 1 line in the mFOLFIRINOX mode, CT4N1M1, stage IV, class II. group Irinotecan + Aflibercept pT4aN1aM0, CV stage, class IV

Operation: "Implantation of the venous port system

Spend standard preparation of the operating field. The non-dominant arm of the patient is treated from the base of the hand to the armpit entirely from all sides. After processing the surgical field and wrapping the operation site with sterile linen, venipuncture v. basilica, which is performed under ultrasound guidance. Ultrasound screening v. Basilica is carried out along its entire length to exclude its thrombosis and features of the anatomical structure. At the time of puncture, a venous tourniquet is used, which is placed in the upper third of the shoulder before processing the surgical field. The use of a tourniquet allows for good blood supply to the vein and increases the size of the vein.

Puncture v. basilica is performed in the region of the middle third of the shoulder. Before vein puncture, local anesthesia of the skin and tissues with a 2% lidocaine solution is performed using a 23 G needle. Depending on the position of the ultrasound probe in relation to the course of the vein, vein puncture is performed with visualization of the needle throughout. When the vein is successfully punctured, a metal J-shaped conductor 83 cm long is inserted through the lumen of the needle, a bougie with an introducer is inserted through the guide into the lumen of the vessel, then the bougie is removed from the introducer, while the introducer and the wire of the guide should remain in the lumen of the vein, then along the string a catheter is inserted through the introducer into the vein, when the catheter reaches a mark of 53 cm, the string is removed from the catheter, the catheter is washed with saline and fluoroscopy is performed to visualize the location of the catheter tip in the superior vena cava, then the introducer is removed from the vein, after catheterization of the main vein and the superior vena cava they begin to form a pocket in the area of the upper third of the forearm, stepping back from the elbow crease by 2.5 cm down, moreover, the size of the incision is made 0.7 cm larger than the diameter of the implanted port, after cutting the skin with a clamp and a hook, the pancreas tissues are pushed apart in a blunt way and form a pocket, with the help of a metal conductor form a tunnel between du subcutaneous fat and superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the tip of the catheter is brought into the pocket and the coupling is put on it, the catheter is cut, put on the port cannula and fixed in this position with the coupling, the port is then dipped into the pocket and sutured to ensure a stable position.

After that, the wound is sutured in layers with absorbable suture material.

The implantation of the venous port system ensures the preservation of an active lifestyle of a cancer patient, the convenience of using the port system in patients with developed subcutaneous fat and high BMI, the absence of scars and skin defects in the décolleté area, and the absence of complications such as hemothorax and pneumothorax.

Bibliography

1. 1-Egiev V.N., Shchetinin V.V., Trofimenko Yu.G. Fully implantable systems in medicine. - M., 2004. - 60 p.

2. 2- Li G, Zhang Y, Ma H, Zheng J. Arm port vs chest port: a systematic review and metaanalysis. Cancer Management Res. 2019 Jul 3;11:6099-6112.

Claims (1)

A method for installing a venous port system, including puncture of the main vein in the region of the middle third of the forearm, characterized in that after puncture of the vein, a metal J-shaped conductor 80 cm or more long is inserted through the lumen of the needle, a bougie with an introducer is inserted through the conductor into the lumen of the vessel, then the bougie is removed from the introducer, while the introducer and guidewire string should remain in the lumen of the vein, then the catheter is inserted into the vein along the string through the introducer, when the catheter reaches a mark of 50-55 cm, the string is removed from the catheter, the catheter is washed with saline and fluoroscopy is performed to visualize the location tip of the catheter in the superior vena cava, then the introducer is removed from the vein, after catheterization of the main vein and the superior vena cava, they begin to form a pocket in the region of the upper third of the forearm, stepping back from the elbow crease by 2-3 cm down, moreover, the size of the incision is made at 0 .5-1.0 cm larger than the diameter of the implantable port, after skin incision using clamp and hook bluntly push the pancreas tissues apart and form a pocket, with the help of a metal conductor a tunnel is formed between the subcutaneous fat and the superficial fascia of the shoulder and forearm from the vein puncture site to the pocket, the catheter is passed through the tunnel, the tip of the catheter is brought out into the pocket and put on it sleeve, the catheter is cut, put on the cannula of the port and fixed in this position with the sleeve, then the port is immersed in the pocket and hemmed to ensure a stable position.