RU2226366C1 - Method for carrying out transmembranous dialysis of omental bursa in the cases of acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out continuous perfusion of osmotic active 33% low molecular weight polyvinyl pyrrolidone solution at a rate of 10 ml/h in membrane capsule cavity set into omental bursa using microperistaltic bicanal pump in postoperative period for 7-9 days. EFFECT: prolonged survival period; accelerated treatment course; reduced risk of purulent complications; eliminated early toxicosis phenomena. 3 cl

Description

The invention relates to medicine, can be used in surgery.

A known method of drainage of the omental bursa in cases of widespread pancreatic necrosis using multi-lumen tubular drainage structures in combination with Penrose rubber-gauze drainage (Annals of Surgery. - 1999.- No. 4.- P.36). This method has the following disadvantages: low efficiency due to rapid occlusion of the lumen of the drainage tubes with tissue detritus, a high risk of secondary infection of the abdominal cavity by sucking in air and infected substrate, ischemia, traumatic edema, sensitization of tissues of the drained area, loss or displacement of drains with prolonged use in postoperative period, as well as large losses of protein and electrolytes.

The closest method of transmembrane drainage of the stuffing bag, proposed by V.A. Fokin (Peritonitis: Materials of scientific and practical conference. Novosibirsk, 1991. - P.74-76), which consists in bringing the capsule from a semipermeable membrane containing a highly osmolar solution dialysate, to the body of the pancreas with a fractional change of the dialysis solution once a day. The proposed method avoids the disadvantages of tubular drainage, however, it has low efficiency due to the mismatch of membrane performance and a progressively increasing concentration of toxic substances in the exudate.

Object of the invention: stopping the phenomena of endotoxemia, reducing the number of postoperative complications, reducing postoperative mortality, reducing the length of hospital stay.

The problem is solved due to the fact that in the postoperative period for 7-9 days using a microperistaltic two-channel pump, continuous perfusion of an osmotically active 33% solution of low molecular weight polyvinylpyrrolidone in the cavity of the membrane capsule is performed at a rate of 10 ml / hour.

The method is as follows: for patients with destructive forms of acute pancreatitis, pancreatic abdomination, stuffing bag marsupialization are performed intraoperatively, and bile duct decompression is indicated for indications. A membrane capsule is installed in the stuffing bag, consisting of a tubular microirrigator with perforations, enclosed in a cavity of a dialysis semipermeable membrane. The proximal membrane capsule through a microirrigator is brought to the pump for active administration of dialysate. The distal section is inserted into the stuffing bag through the marsupialization opening, laid along the pancreas bed, removed through contra-holes in the left hypochondrium and connected to the second channel of the pump with the help of a micro-irrigator for constant aspiration. In the postoperative period for 7-9 days using a microperistaltic two-channel pump, continuous perfusion of the osmotically active 33% solution of low molecular weight polyvinylpyrrolidone in the cavity of the membrane capsule is performed at a rate of 10 ml / hour.

Under observation were 18 patients with various forms of destructive pancreatitis (table. 1). The diagnosis was made on the basis of clinical and laboratory data, the results of an ultrasound examination and, if indicated, diagnostic laparoscopy.

Intensive therapy was continued for a day. Indications for surgical treatment were the lack of effect of conservative therapy, an increase in the clinic of peritonitis and signs of endogenous intoxication, non-stopping acute pancreatitis with increasing jaundice.

Early operations were performed within the period from 24 to 48 hours from the moment of patients admission to the hospital. Operations were performed under intubation anesthesia. Laparotomy was performed by mid-median access. After opening the abdominal cavity, peritoneal effusion was removed sequentially from the upper abdomen, left side channel, pelvis and right side channel. We examined the omentum, mesentery of the transverse colon and small intestine, gall bladder and common bile duct, as well as the duodenum. We ascertained the presence of edema, hemorrhage, and foci of steatonecrosis in these organs.

In 15 patients, the cause of pancreatic necrosis was destructive cholecystitis in combination with cholecystocholangiolithiasis. Conducted cholecystectomy, choledochotomy, external drainage of the common bile duct according to Vishnevsky, pancreatic abdomination. After marsupialization, a membrane capsule was installed in the stuffing bag, consisting of a tubular microirrigator with perforations, enclosed in a cavity of a dialysis semipermeable membrane. The proximal portion of the membrane capsule was brought through a microirrigator to a pump for active administration of dialysate. The distal section was inserted into the stuffing bag through the marsupialization opening, laid along the pancreas bed, removed through contrapertures in the left hypochondrium and connected to the second channel of the pump using a microirrigator for constant aspiration. The operation was completed by drainage of the free abdominal cavity, nasointestinal intubation of the small intestine.

In the postoperative period, an osmotically active 33% solution of low molecular weight polyvinylpyrrolidone was continuously perfused with a microperistaltic two-channel pump in the cavity of the membrane capsule at a rate of 10 ml / hour. The reason for stopping dialysis and removing the membrane capsule from the stuffing bag was the absence of signs of progression of pancreatic necrosis, clinical and laboratory manifestations of endogenous intoxication syndrome. On average, the duration of flowing transmembrane drainage of the stuffing bag was 7–9 days. Removing the membrane drainage device from the stuffing bag was technically simple and painless after it was released from the dialysate.

In the first eight days, clinical blood tests, biochemical blood and dialysate tests were performed daily, and the luciferase index (L.I.) of exudate and blood serum was determined.

In patients with destructive forms of acute pancreatitis, a high level of endogenous intoxication was already observed upon admission to the hospital. The leukocyte intoxication index (LII) was 3.4 ± 0.7 cu, leukocytosis 21.6 ± 2.3 × 10 ⁹ / L. The content of MSM was 0.596 ± 0.048 cu Malondialdehyde (MDA) increased to 11.4 ± 0.6 mmol / L, urea to 9.18 ± 0.7 mmol / L, bilirubin to 28.82 ± 2.3 mmol / L, amylase to 56 ± 4, 4 mg / s • l. LI was 0.73 ± 0.08 cu, which corresponds to severe intoxication.

During the first days after the operation, a decrease in total blood toxicity was noted, the number of leukocytes, the level of amylase decreased, but the differences in these terms were not significant.

The serum MSM content in 1 day decreased by 10.7% (0.530 ± 0.043 cu), by 5 days - by 54.9% (0.269 ± 0.036) and by 8 days of the postoperative period - by 66.9% (0.197 ± 0.013 cu). The accumulation of MSM in dialysate reached its maximum value on the 3rd day of the postoperative period (Fig. 1). The urea level decreased 1.8 times by 5 days after surgery, amounting to 5.1 ± 0.9 mmol / l (figure 2).

The luciferase index of blood, peritoneal exudate reached its maximum values in the first day after surgery and progressively decreased over the next 7 days. By the eighth day, the LI of serum was 0.27 ± 0.04 cu (P <0.05) (FIG. 3).

By 5 days, leukocytosis decreased to 8.2 ± 0.47 • 10 ⁹ / L (P <0.05). LII remained elevated. Lipoperoxidation rates decreased, MDA - 6.9 ± 0.7 μmol / L. Amylasemia was reduced to 11.7 ± 0.9 mg / s • l (P <0.05). AcT activity decreased to 0.31 ± 0.07 mmol / h • l, and ALT to 0.47 ± 0.05 mmol / h • l, which corresponded to the upper limit of the norm. The values of the de Ritis coefficient increased to 0.68 ± 0.07 cu (P <0.05). The thymol sample was reduced to 3.1 ± 0.73 units. (P <0.05). The level of bilirubin decreased to normal, the activity of alkaline phosphatase - to 248.1 ± 13.7 nmol / s • l (P <0.05). Indicators of potassium, sodium, calcium, total protein content remained within normal limits.

Postoperative mortality during flow transmembrane dialysis of the stuffing bag was 16.6%. The average duration of treatment of patients in the hospital was 21.3 ± 2.4 days (figure 4).

The causes of death of patients were pulmonary embolism (one patient), acute myocardial infarction (one patient), and arrosive bleeding that occurred in one patient in the third week of the disease. Rehabilitation relaparotomy was not required for patients with flowing transmembrane dialysis of the stuffing bag.

The comparative group consisted of 20 patients with destructive pancreatitis who were treated at City Clinical Hospital No. 7 of Krasnoyarsk from 1998 to 2001. Postoperative mortality in this group of patients averaged 27.8%, average hospital bed 31.3 ± 2.6 days.

Thus, the use of flow transmembrane dialysis of the stuffing bag allows to reduce mortality in case of destructive pancreatitis by 11.2%, to reduce the recovery time of patients by an average of 10 days due to the early elimination of the phenomena of endotoxemia, and the prevention of purulent complications.

The achieved positive effect can be explained by the long-term maintenance of the concentration gradient of toxic metabolites on opposite sides of the semipermeable membrane with continuous perfusion of the osmoactive solution, which allows constant absorption of peritoneal fluid in combination with the elimination of toxins.

Example 1. Patient B. 34 years. East bol. No. 5621, was admitted to the surgical department No. 1 of the City Clinical Hospital No. 7 of Krasnoyarsk on 12/21/1999 at 5 o’clock with a diagnosis of acute cholecystitis. Complaints upon receipt of constant pain in the right hypochondrium and epigastric region, repeated repeated vomiting of gastric contents, which does not bring relief, general weakness. He considers himself ill for about 36 hours, when after eating spicy foods, intense abdominal pain appeared. There were no such attacks before. The patient’s condition is serious at admission, the skin is pale, the sclera is icteric, the pulse is 116 rpm, rhythmic, blood pressure is 120/80 mm Hg, vesicular breathing, heart sounds are rhythmic. The tongue is moist, densely lined with white plaque at the root. The abdomen is slightly swollen, stiff, painful in all departments, intestinal noises are audible. Positive symptoms of Mayo-Robson, Voskresensky, Ortner, Kera. No swelling. Blood tests showed leukocytosis (20.4 • 10 ⁹ / l), accelerated ESR, hyperamilasemia (64.6 mg / s • l), hyperbilirubinemia (total bilirubin - 46.2 μmol / l, direct - 20.4 μmol / l, indirect - 25.8 μmol / l), an increase in the content of malondialdehyde (11.2 μmol / l), the level of molecules of average weight (0.38 cu). 12.21.1999 FGDS Conclusion: duodeno-gastric reflux, atrophic gastritis. For 18 hours, the intensive care unit carried out a set of conservative measures, including detoxification therapy in the regime of forced diuresis, the use of antispasmodics, cytostatics (5-fluorouracil, dalargin), antiplatelet agents, nasogastric drainage with gastric lavage. Despite the therapy, the patient's condition remained serious, signs of endogenous intoxication progressed, and symptoms of peritoneal irritation appeared. Ultrasound of the abdominal cavity from 12/21/1999: In the abdominal cavity in the small pelvis and on the right side channel, free fluid is determined. In the stuffing bag with the spread to the area of the tail of the pancreas, free fluid with a layer thickness of up to 24 mm. In the gallbladder, multiple calculi up to 6-7 mm in diameter. Choledoch 11 mm. Conclusion: ZhKB. Signs of biliary hypertension. Omentobursitis. Spilled peritonitis.

12/21/1999 at 23 hours. performed median laparotomy. An audit of the abdominal cavity revealed: phlegmonous calculous cholecystitis, cholangiolithiasis, subtotal infected pancreatic necrosis, diffuse enzymatic peritonitis. Performed cholecystectomy, choledocholithotomy, choledoch drainage according to Halsted-Pikovsky, pancreatic abdominization, marsupialization, through transmembrane drainage of the omental bursa, debridement, abdominal drainage, nasointestinal small intestine intubation. In the postoperative period, flowing transmembrane dialysis of the stuffing bag was performed for 8 days. Drainage from the abdominal cavity was removed on the 4th day, the membrane device was removed from the stuffing bag on the 8th day, drainage of the common bile duct - on the 14th day. Ultrasonic control from 12.29.1999: there is no free fluid in the abdominal cavity, there is no stuffing bag, moderate diffuse changes are observed in the pancreas, head - 26 mm, body - 17 mm, tail - 22 mm.

In blood tests 12/30/1999: leukocytes 9.1 • 10 ⁹ / l, acceleration of ESR up to 20 mm / h, amylase 5.6 mg / s • l, total bilirubin - 12.6 μmol / l, direct - 2, 4 μmol / L, indirect - 10.2 μmol / L), malondialdehyde 2.7 μmol / L, medium-weight molecules - 0.22 cu Signs of progression of pancreatic necrosis were not detected. On the 18th day the patient was discharged in satisfactory condition.

The advantage of the proposed method compared to others lies in the early and effective detoxification, preservation of the drainage properties of the device used during the entire time of use, the absence of sensitization of the tissues of the drained area, elimination of protein and electrolyte losses, as well as the non-invasiveness of the installation and extraction of the membrane device.

Claims (1)

The method of flowing transmembrane dialysis of the stuffing bag in acute destructive pancreatitis, which includes installing a membrane capsule in the stuffing bag, consisting of a tubular microirrigator with perforations, enclosed in a cavity of a dialysis semipermeable membrane, the proximal section of which is fed through the microirrigator to the pump for the active introduction of dialysate, the marsupialization opening is inserted into the stuffing bag, laid along the pancreas bed, and removed through the con raperture in the left hypochondrium and using a microirrigator is connected to the second channel of the pump for continuous aspiration, characterized in that in the postoperative period for 7-9 days, an osmotically active 33% solution of low molecular weight polyvinylpyrrolidone is continuously perfused in the cavity of the membrane capsule with 10 ml / h.

Images