RU2741465C1 - Method of throughfistulous videoscopic necrosequestrectomy in purulent-necrotic parapancreatitis - Google Patents

Abstract

FIELD: medicine; abdominal surgery.SUBSTANCE: percutaneous puncture of the omental pouch cavity to the pathological area through the gastro-collar ligament is performed, with the condition of bypassing vascular structures, parenchymal and hollow organs, pleural sinuses, followed by 2–3 rigid conductors through the needle into the omentum chamber. Paracentetic channels are bored and 2–3 bio-inert tubes with diameter 28–32 serving are introduced. Then, 7–10 days later, in one of the formed channels, at the point of percutaneously installed tubes, a flexible endoscope is inserted, working tool—laparoscopic clamp with ribbed inner surface or dissector—is delivered through another channel. To working field, physiological solution is supplied through working channel of endoscope for visualization of freely lying sequesters and washing of stuffing box, with fragmentation and removal of sequestrants with a working tool, wherein a working solution of the endoscope or through a tube-formed channel of a vacuum aspirator is used to extract a washing solution with fine fragments of the remaining sequesters. Thereafter, under the control of the endoscope, double-lumen drainages are placed in each tube formed by tubes and fixed to skin for further fractional washing of the omental chamber cavity. If the patient's clinical-laboratory dynamics is negative, the drains are removed and the necrosequestrectomy is repeated along the formed channels. If observing the positive clinical-laboratory dynamics of the patient's state under X-ray control, the drainages are replaced and every 6 hours, washing is continued to achieve clean flushing water outlet.EFFECT: method makes it possible to create full-value additional accesses to the omental bag, to improve the treatment results by reducing a suppurative-necrotic omental process using minimally invasive techniques and minimizing an operating injury, reducing a risk of intraoperative complications when removing sequesters, reducing mortality.1 cl, 2 ex

Description

The proposed invention relates to the field of medicine, namely to surgery, and can be used in the treatment of patients with pancreatic necrosis in the sequestration phase.

The modern approach to the treatment of pancreatic necrosis has a differentiated approach: at an early stage, it is a general effect on the body aimed at stopping the phenomena of endotoxicosis and multiple organ failure (A.B. Valchinskaya et al., 2017; S.N. Styazhkina et al., 2017; K. Joglekar et all., 2017), late - adequate local treatment (EL Bradley et all., 2010; HJ Amano et all., 2010).

Surgical methods for the treatment of pancreatic necrosis in the later stages include the following: open, semi-open (traditional) and closed (V.S.Saveliev et al., 2008; K. Wada et all., 2010), the main tasks of which are to ensure an adequate outflow of exudate, removal of sequesters, preferably with minimal surgical trauma (Yu.V. Kulezneva, 2016; MW Buchler et all., 2000).

However, the above methods of surgical treatment do not always help in solving the assigned tasks, such as significant surgical trauma, secondary infection, insufficiently radical drainage (A.A. Rebrov et al., 2012; V. Andersson et all., 2010).

An analogue of the proposed method of necrsextrectomy is the sanitation of purulent-necrotic foci of the abdominal cavity and retroperitoneal space in acute destructive pancreatitis, proposed by A.V. Onopriev, M.L. Rogal, E.Yu. et al. (RU 2311873 C2 IPC А61В 17/00; А61В 1/273; A61K 49/04; А61Р 43/00). The essence of the method is as follows: the patient is introduced with an endoscope and placed on his stomach. Find the fistulous opening along the back wall of the stomach or in the area of the back wall of DNA. A gastroscope is inserted into the fistulous opening, under visual and X-ray control. The endoscope is inserted into the purulent-necrotic cavity and sanitized by washing it with antiseptic solutions, the existing necrotic sequesters are crushed with biopsy forceps, passed through the working channel of the endoscope and washed out of the cavity with a stream of solution supplied under pressure. After aspiration of the contents, fistulography is performed in the same volume through the installed catheter. Further, through the working channel of the gastroscope, a transnasal drainage is installed for subsequent sanitation of the cavity.

Disadvantages of the method:

- the method provides for the mandatory presence of a fistula between the stomach and the retroperitoneal space;

- the creation of increased pressure during the manipulation can contribute to the spread of exudate and rinsing solution through the retroperitoneal tissue;

- a small working part of the instrument makes it difficult to remove sequesters, and also increases the risk of anesthetic benefits due to the increasing duration of the operation;

- the use of biopsy forceps does not allow tissue dissection, as well as instrumental palpation;

- the used long, thin transnasally installed drainage along the working channel of the gastroscope does not provide an adequate outflow of exudate and removal of sequesters;

- the need to give the patient a prone position during the procedure helps to reduce chest excursion, which can lead to the progression of respiratory failure.

As the closest analogue, the study described by Carter, C.R. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience / C.R. Carter, C.J. McKay, C.W. Imrie // Ann. Surg. - 2000. - Vol. 232, No. 2. -P. 175-180. With this method, an access is made under CT control through the gastro-colonic ligament or between the lower pole of the spleen and the splenic flexure of the large intestine, 8 Fr drainage with a “pig tail” design is introduced into the cavity, then the patient in the operating room is bougienated to 30 Fr. With the help of a nephroscope, using intermittent irrigation and suction, free-lying areas of sequesters are removed, hard and tightly fixed areas are separated using a soft clamp or forceps through the working channel by repeatedly inserting the instrument into the cavity. The intervention is completed by installing an 8 Fr drainage with a “pig tail” structure, which is located in a 28 Fr tubular drain for continuous postoperative flushing (500 ml / h).

Disadvantages of the method:

- the method does not provide for full access to the omental bursa due to the formation of one puncture canal;

- the small diameter of the working channel of the nephroscope (4 mm) does not allow to fully sanitize the omental bursa, due to its blockage with large fragments of sequesters;

- the absence of formed wound channels increases the risk of exudate and lavage fluid leaking into the free abdominal cavity;

- removal of fixed sequesters without the use of instrumental imaging methods increases the risk of intraoperative complications;

- alternate introduction of a nephroscope and a working instrument lengthens the time of surgery, complicates the technical performance;

- continuous postoperative lavage (500 ml / h) can promote fluid retention and the spread of exudate through the retroperitoneal tissue.

Tasks:

- creation of full-fledged accesses to the omental bursa taking into account the subsequent performance of transfistular videoscopic necrsequestrectomy;

- minimization of surgical trauma;

- relief of the purulent-necrotic process of the omental bursa;

- reducing the risk of intraoperative complications when removing sequesters;

- decrease in mortality.

The essence of the method is that using a needle for primary access under ultrasound control, percutaneous puncture of the omental bursa cavity is carried out through the gastro-colonic ligament, with the condition of bypassing vascular structures, parenchymal and hollow organs, pleural sinuses, followed by passing through a needle 2-3 -x rigid conductors into the cavity of the stuffing box, bougienage of the puncture canals is performed and 2-3 bioinert tubes with a diameter of 28-32 Fr (French) are inserted, then after 7-10 days a flexible endoscope is inserted into one of the formed channels at the site of the percutaneously installed tubes, through the other channel is supplied to the sequestration with a working instrument - a laparoscopic clamp with a ribbed inner surface or a dissector, physiological solution is supplied to the working field through the working channel of the endoscope to visualize free-lying sequestra and flush the omental bursa, with fragmentation and removal of sequestrates with a working instrument, and through the working channel of the endoscope or through the form The canal lined with tubes with a vacuum aspirator sucks out the wash solution with small fragments of the remaining sequestrates, after which, under the control of the endoscope, double-lumen drains are installed and fixed to the skin in each canal formed by the tubes for subsequent fractional washing of the cavity of the omental bursa; with negative clinical and laboratory dynamics of the patient's condition, the drains are removed and necrsequestrectomy is repeated along the formed channels, and with a positive clinical and laboratory dynamics of the patient's condition under X-ray control, the drains are replaced and washing is continued every 6 hours until the outlet of clean wash water is reached.

The method was tested for 10 years on 147 patients.

EFFECT: creation of full-fledged additional approaches to the omental bursa for the subsequent provision of an increase in the effect of transfistular videoscopic necrsequestrectomy, improvement of treatment results by stopping the purulent-necrotic process of the omental bursa using minimally invasive technologies and minimizing surgical trauma, reducing the risk of intraoperative complications when removing sequesters using visual methods control, reduced mortality.

Approbation of the method allowed to reduce mortality from 48 to 16.7%.

The method is carried out as follows.

Using a needle for primary access under ultrasound control, percutaneous puncture of the omental bursa cavity is carried out through the gastro-colonic ligament with the condition of the shortest maximally rectilinear path to the pathological focus far from the vascular structures, parenchymal, hollow organs and pleural sinuses and insertion through the lumen of the needle 2 -3 rigid conductors in the stuffing box; then, by bougage of the puncture canal, 2-3 bioinert (drainage) tubes with a diameter of 28-32 Fr (French) are introduced.

Subsequently, within 7-10 days, channels are formed in the place of the installed percutaneous drainage tubes to seal the channels and delimit them from the free abdominal cavity. Then, after the channels have formed, a flexible endoscope is inserted through one channel, and a laparoscopic clamp with a ribbed inner surface or a dissector through the other; through the third channel (if any), a silicone drainage tube is inserted, connected to an electric aspirator.

Saline is periodically fed to the working field through the endoscope to visualize free-lying sequesters and partial washing of the omental bursa; the working tool performs fragmentation and step-by-step removal of free-lying and fixed sequesters, the evacuation of the washing solution is carried out through a drainage tube connected to an electric aspirator.

The intervention continues until all formed sequesters are removed as much as possible.

Surgical intervention is completed with the installation of double-lumen drainages through the formed channels under visual endoscopic control, with their location in the drained cavities, followed by fractional washing of cavities in the postoperative period with aqueous solutions of antiseptics (aqueous solution of chlorhexidine, sodium hypochlorite, etc.). With negative clinical, laboratory and instrumental dynamics of the patient's condition, the drains are removed and repeated necrsequestrectomy is performed through the formed canals in the above-described manner, and with positive dynamics, washing is continued at intervals of 6 hours each time until visually clear rinsing water is obtained, while the drains are periodically replaced with new ones under X-ray control, until complete sanitation of the pathological focus.

Clinical example 1. Patient V., 32 years old, was transferred to the clinic from the central regional hospital on January 16, 2017, on the 20th day from the onset of the disease, with a diagnosis of "Infected pancreatic necrosis, purulent-necrotizing parapancreatitis." Operation 17.01.2017 "Drainage of the stuffing box under ultrasound control." In the operating room, under ultrasound guidance, using a primary access needle, a percutaneous puncture of the fluid accumulation of the omental bursa was performed through the gastro-colonic ligament, two rigid conductors were installed; with the help of a bougie, the puncture canal was expanded to a diameter of 28 Fr, and two double-lumen drainages with a diameter of 28 Fr were installed in the omental bursa.

In the postoperative period, the omental bursa was washed through the established drainages with an aqueous solution of chlorhexidine every six hours until visually clear washings appeared. In the postoperative period, the patient's condition remained stably severe, and her low-grade fever persisted. Seven days after the primary operation, a second operation was performed on 01.24.2017: "Omentobursoscopy, transfistular videoscopic necrsequestrectomy". In the operating room, the double lumen drains were removed, a flexible endoscope was inserted through the formed channel, during omentobursoscopy the formed sequesters were revealed, and a laparoscopic clamp was inserted through the other channel.

Saline was periodically fed to the working field through the endoscope for washing the omental bursa, fragmentation and removal of sequesters were performed with the working instrument under visual instrumental control, and the washing solution was removed through the working channel of the endoscope.

The intervention continued until all the formed sequesters were removed as much as possible.

Surgical intervention was completed with the installation of double-lumen drainages through the formed canals under visual endoscopic control, with their location in the drained cavities.

In the postoperative period, the cavity was washed with an aqueous solution of chlorhexidine according to the above procedure.

There was a moderate positive clinical and laboratory dynamics of the patient's condition. On 31.01.2017, a repeated operation was performed: "Omentobursoscopy, transfistular videoscopic necrsequestrectomy"; during the intervention, a decrease in the amount of sequestral tissue was revealed. In the postoperative period, there was a positive clinical and laboratory dynamics of the state.

02/07/2017, 02/14/2017, 02/21/2017, 02/28/17 programmed replacements of the stuffing box drainage were performed under X-ray control. Due to the positive dynamics, the normalization of indicators, 03/04/2017 the patient was discharged in a satisfactory condition for further treatment at the central district hospital at the place of residence with drainages.

04/03/2017 Patient V. was hospitalized for a control examination. There is no drainage discharge; fistulography was performed, on which obliteration of the pathological cavity is noted; drains removed.

Clinical example 2. Patient A., 41 years old, was admitted to the clinic on 05/03/2016. Considers himself ill for about 3 weeks, was treated conservatively in the Central Regional Hospital at the place of residence, with negative dynamics and non-stopping febrile temperature, was sent to the clinic of KKB No. 2. Upon admission, he was in a serious condition due to sepsis, and was hospitalized in the intensive care unit. After a set of diagnostic measures (ultrasound, FGDS, laboratory tests), a clinical diagnosis was established: "Infected pancreatic necrosis, purulent-necrotic parapancreatitis." After the necessary preoperative preparation, the patient underwent an operation on 05/04/2016: "Drainage of the omental bursa under ultrasound control." In the operating room, under ultrasound guidance, using a primary access needle, percutaneous puncture of the fluid accumulation of the omental bursa was performed through the gastrocolic ligament, three rigid conductors were installed, the puncture canal was expanded to a diameter of 32 Fr with the help of a bougie, and three double-lumen drainages with a diameter of 32 Fr were installed in the omental bursa. ... In the postoperative period, the omental bursa was rinsed with an aqueous solution of chlorhexidine every six hours until visually clear rinsing water appeared through the installed drains.

The patient's condition improved, but after 9 days the temperature rises to febrile figures in the evening. Ten days after the primary surgery, repeated surgery was performed on 05/14/2016; "Omentobursoscopy, transfistular videoscopic necrsequestrectomy". In the operating room, double-lumen drains were removed, a flexible endoscope was inserted through the formed channel, formed sequesters were revealed during omentobursoscopy, a laparoscopic clamp was inserted through another channel, a drainage tube was inserted through the third channel, connected to an electric aspirator to remove the wash solution.

Saline was periodically fed to the working field through the endoscope for washing the omental bursa, fragmentation and removal of sequesters were performed with a working tool under visual instrumental control, removal of the washing solution was carried out through the third channel through a drainage tube connected to an electric aspirator.

The intervention continued until all the formed sequesters were removed as much as possible.

Surgical intervention was completed with the installation of double-lumen drainages through the formed canals under visual endoscopic control, with their location in the drained cavities.

In the postoperative period, the cavity was washed with an aqueous solution of chlorhexidine according to the above procedure.

05/21/2016, 05/28/2016, 06/05/2016 programmed replacements of the stuffing box drainage were performed under X-ray control. Due to the positive dynamics, normalization of indicators, 06/07/2016 the patient was discharged with drains for further treatment at the Central District Hospital in a satisfactory condition.

07/02/2016 Patient A. was hospitalized for a control examination. There is no drainage discharge; fistulography was performed, on which obliteration of the pathological cavity is noted; drains removed.

Claims (1)

The method of transfistular videoscopic necrsequestrectomy for purulent-necrotizing parapancreatitis, including providing access to the pathological zone, the formation of a puncture canal using a needle for primary access under ultrasound control, characterized in that percutaneous puncture of the omental bursa cavity to the pathological zone through the gastro-colonic ligament with the condition of bypassing vascular structures, parenchymal and hollow organs, pleural sinuses, followed by passing 2-3 rigid conductors through the needle into the cavity of the omental bursa, bougienage of puncture canals and inserting 2-3 bioinert tubes with a diameter of 28-32 French, then after 7 -10 days, a flexible endoscope is inserted into one of the formed channels at the site of the percutaneously installed tubes, through another channel a working instrument is brought to the sequestrators - a laparoscopic clamp with a ribbed inner surface or a dissector, a saline solution is supplied to the working field through the working channel of the endoscope for visualization of free-lying sequesters and washing of the omental bursa, with fragmentation and removal of sequesters with a working tool, and through the working channel of the endoscope or through the channel formed by the tubes, a vacuum aspirator sucks the wash solution with small fragments of the remaining sequesters, after which, under the control of the endoscope, in each channel formed by the tubes is installed and double-lumen drainages are fixed to the skin for subsequent fractional washing of the omental bursa cavity, with negative clinical and laboratory dynamics of the patient's condition, the drains are removed and necrsequestrectomy is repeated through the formed channels, and with positive clinical and laboratory dynamics of the patient's condition under X-ray control, the drains are replaced and every 6 hours continue washing until the outlet of clean wash water is reached.