RU2523147C1 - Method of treating distal pancreatic injuries in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: distal pancreatic injuries in children require removing fragments. Crushed tissues are resected. A haemorrhage is arrested. In-turning Z-sutures are applied on a pancreatic stump. The left descending vascularised greater omentum strand is laid about a drain tube as a duplex.

EFFECT: method provides the optimum sealing of the pancreatic stump with sutures, and of the drain with a greater omentum fragment, prevents formation of fistulas, false cysts, progressing peritonitis, paranephritis, and re-laparotomy.

1 ex, 4 dwg, 1 tbl

Description

The present invention relates to medicine, in particular to the surgical treatment of injuries of the distal pancreas in children.

Pancreas injury in children with combined lesions of the abdominal organs occurs in 10% of cases.

In traumatic central ruptures of the spleen, fragmentation (crushing) of the pancreatic tail usually occurs.

For such injuries, the following standard surgical treatment is used:

1. Remove loose fragments of the gland;

2. Stop bleeding by thermocoagulation;

3. Drain the cavity of the small omentum with a silicone drainage tube through an additional incision in the left lumbar region.

However, in the postoperative period, there is often a need for relaparatomy for peritonitis (10.7% of cases), the formation of false cysts (3.6% of cases), the formation of pancreatic fistula (7.1% of cases), due to the spread of the inflammatory process in the abdominal cavity.

The well-known "Method for the surgical treatment of chronic pancreatitis" (RF Patent No. 02421158 from 06/20/2011), including subtotal resection of the pancreatic head, drainage of the omental bursa on the anterior abdominal wall, sealing the drainage channel by wrapping it with a lock of a large omentum.

The disadvantages of the described analogue are the various methods and places of drainage of the damage zone, the absence of sealing joints, which can lead to the spread of the inflammatory process in the intact part of the abdominal cavity.

Closest to the proposed invention, the technical solution adopted for the prototype is the "Method for the treatment of purulent pancreatitis" (RF Patent No. 2064779, published on 08/10/1996), including resection of the pancreas, stopping bleeding by thermocoagulation, application of Z-shaped sutures on the pancreatic stump glands, the location in the cavity of the small omentum of the drainage tube with side openings on one side, the sealing of the drainage tube with a fragment of the omentum on the vascular pedicle by fixing it with separate sutures to the pairs to the peritoneum using an additional window in a large omentum fragment.

The disadvantages of the prototype include: stopping bleeding by thermocoagulation, which leads to additional trauma and inflammation of the pancreas, fixation of a large omentum fragment with sutures to the parietal peritoneum using an additional window, which leads to the spread of the inflammatory process in the abdominal cavity and in the paranephral region.

The aim of the invention is to minimize the possibility of manifestations in the postoperative period of such complications as peritonitis, the formation of false cysts and pancreatic fistula, due to the spread of the inflammatory process in the abdominal cavity, perinephral and other areas and, as a consequence, eliminating the need for relaparatomy, which is especially important for physiological the state of the child's body.

The technical result of the proposed method for the treatment of injuries of the distal pancreas in children is:

1. Optimal sealing of the pancreatic stump and drainage, which prevents the spread of the inflammatory process to the abdominal cavity, perinephral region;

2. Reduction of stay in the intensive care unit;

3. Reducing the period of hospital treatment;

4. Prevention of the development of pancreatic fistula, false cysts, progressive peritonitis and paranephritis;

5. Elimination of the need for relaparatomy.

Proposed as an invention, a method of treating injuries of the distal pancreas in children is carried out in the following order, which is illustrated by the illustrations presented in figures 1-4.

After opening the abdominal cavity, bleeding from the damaged spleen or liver, which threatens the life of the child, is stopped and a visual examination of the small omentum cavity is performed for damage to the distal part of the pancreas (Figure 1).

Further surgical treatment of damage to the distal part of the pancreas is performed according to the claimed method. Freely lying fragments 1 are removed and partially, within the limits of healthy tissues, crushed pancreatic tissues are excised 2. Stop bleeding. After that, they seal, i.e. sutured, given the vascular architectonics, the pancreatic stump with three Z-shaped sutures that perform screw 4 (Figure 2). Upon completion of the sealing of the stump, the left descending strand 5 of the greater omentum 6 on the vascular pedicle is cut out (Figure 3). Place a drainage tube 7 with side openings in the direction of the line of screw-in Z-joints for evacuation from the cavity of the small stuffing box seal. Then the cut left downward strand of the greater omentum is placed around the drainage tube in the form of a duplicate 8. The drainage tube is brought out through an additional incision in the left lumbar region (Figure 4).

The practical feasibility of the claimed method is illustrated by an example from clinical practice.

Example: patient K., 13 years old, was admitted to the clinic of pediatric surgery at Rostov State Medical University on the basis of the city hospital No. 20 after an accident, in which he received a direct bumper bump to the left side of the abdominal cavity. Upon admission, the patient’s condition K. is severe, traumatic shock of the second degree, erectile phase. Clinically determined signs of intra-abdominal bleeding, which were confirmed by ultrasound - free fluid, mainly in the left side channel of the abdominal cavity. Patient K. had sharp abdominal pains, with irradiation to the lumbar region on the left. Closed head injury, concussion of a severe degree. Multiple abrasions of the lower extremities, multiple closed fractures of the upper third of the bones of the left lower limb.

According to emergency indications, a laparotomy was performed with an upper midline incision. In this case, up to 700.0 ml of blood was evacuated. A central rupture of the spleen was detected with a transition to the vascular pedicle, with a partial detachment of the organ. Extensive hematoma of the mesenteric root and cavity of the lesser omentum. Due to the impossibility of performing organ-sparing surgery, a splenectomy was performed with separate doping of the vascular pedicle. During the audit of the cavity of the small omentum, damage was found - a traumatic detachment of the distal part - the tail of the pancreas; a freely lying gland fragment 1.0 × 0.5 × 1.5 cm in size. A pancreatic fragment was removed. Resected pancreatic tissue was resected. The bleeding was stopped. Then the pancreatic stump was sutured by applying three screwed Z-shaped sutures with absorbable suture material - safil 6/0 atraumatic needle. Sutures were applied in the intervascular zone. They carved out the left descending strand of a large omentum on a vascular pedicle. An additional incision was made in the left lumbar region, through which a silicone drainage tube with two lateral openings was inserted. The tube was connected to the seam line. Then, the drainage was sealed with a lock of omentum on the vascular pedicle, for which it was placed around the drainage tube in the form of a duplicate. The abdominal cavity is drained. The hemostasis test is dry. Performed novocaine blockade of 0.5% -20.0 ml of regional pancreatic tissue. Additionally performed autologous transplantation of splenic tissue. The laparotomy wound is sutured in layers tightly.

In the postoperative period, patient K. was prescribed two antibiotics, anti-shock therapy, hemostatic therapy, symptomatic therapy, infusion therapy in the amount of physiological needs and pathological losses. Treatment of post-traumatic pancreatitis included: octereotide 100 μg × 3 times a day, H2-blockers and proton pump inhibitors — squamate 10 mg / kg × 2 times a day, omeprazole 1 capsule 2 times a day. Installed nasogastric tube, cold on the abdominal wall. During the first day, about 40.0 ml of hemorrhagic discharge was released from the cavity of the lesser omentum through the drainage tube.

Separated drainage stopped by the fourth day, drainage removed. Peristalsis appeared on the fourth day, the gases went away, and stool was obtained, which indicates the relief of intestinal paresis. On the fifth day, child K. was transferred from the intensive care unit to the general ward of the surgical department. Laboratory indicators of pancreatitis activity returned to normal by the fifteenth day (amylase - 1.5 IU / L, ALT - 18 IU / L, ACT - 15 IU / L, alkaline phosphatase - 73 IU / L). The drainage tube is removed on the fourteenth day. The laparotomy wound healed by primary intention. The patient was discharged on the eighteenth day after the operation, in satisfactory condition, with a plaster cast fixing the fracture of the lower leg bones.

The study of follow-up history in child K. testified to the absence of complications in the form of fistulas and false cysts. The moderate clinical signs of adhesive disease of the abdominal cavity were determined. Periodic abdominal pain after taking a large amount of slag-forming food. About which once every six months a course of anti-adhesion therapy was carried out.

The proposed method for the treatment of injuries of the distal pancreas in children was applied in twenty patients (the main group) with combined trauma of the abdominal organs, which significantly reduced the number of postoperative complications.

For comparison, we conducted a retrospective analysis of twenty-eight case histories (control group) of children with combined trauma of the abdominal organs, the treatment of which was performed according to standard methods.

The positive effect of the application of the inventive method is confirmed by the table below.

Table Criteria for evaluation The main group, n = 20 The control group, n = 28 The period of hospital treatment, (average bed / day) 24 42 Period of stay in the intensive care unit 6 16 Pancreatic fistula - 2 (7.1%) False cysts - 1 (3.6%). Progressive peritonitis, paranephritis - 3 (10.7%) Relaparotomy - 5 (17.8%)

Claims (1)

A method for treating injuries of the distal pancreas in children, including removal of freely lying fragments and resection of crushed pancreatic tissues, stopping bleeding, applying Z-shaped sutures to the pancreatic stump, placing a drainage tube with side openings with side openings on one side, sealing drainage tube with a large omentum fragment on the vascular pedicle, characterized in that the Z-shaped sutures applied to the pancreatic stump are performed by screwing in yuschimisya, and a fragment of the greater omentum - it left the descending strand - are placed around the drainage in the form of duplikatury.

Images