The method of surgical treatment of infected pancreatic a pancreatic pseudocyst of the spleen

 

(57) Abstract:

The invention relates to medicine, namely to surgery, and can be used in the treatment of the pancreatic pancreatic pseudocyst and abscess of the spleen. Remove purulent-necrotic content saving the parenchyma of the spleen under the control of ultrasonic tomography. Using percutaneous drainage by needle channel in the intercostal space. Intercostal period corresponds to the lesion. The method allows to speed up the process of restitutie foci of pancreatic destruction. 2 Il.

The invention relates to medicine, namely to surgery, and can be used in the treatment of the pancreatic pancreatic pseudocyst and abscess of the spleen.

With the introduction into clinical practice the latest diagnostic equipment (ultrasound, x-ray, magnetic resonance imaging) with the opportunity to identify and correct interpretation of such complications destructive pancreatitis as intraorganic the pseudocyst and abscess, previously considered rare (A. A. Kuragin, E. A. Nechaev, A. D. Smirnov Surgical treatment of cysts of the pancreas. - S.-Petersburg, 1996; Blandino-A; Scribano-E; Aloisi-G; Visalli-C; Pandolfo-I // Abdom-Imaging. 1996 Jan-Feb; 21(1):the eye may remain undiagnosed (note surgeons focused on the elimination of pancreatic accumulations in the retroperitoneal peripancreatic tissue), to exacerbate the underlying disease course, to cause the development of peritonitis due to rupture of the capsule of the spleen and bleeding into the abdominal cavity.

There is a method of surgical treatment of abscesses of the spleen - splenectomy (I. Littmann. Operative surgery.- Budapest, 1982), involving laparotomy in the left hypochondrium, the mobilization of the gastro-splenic and pancreatic-splenic ligament with legirovaniem and the intersection of the splenic artery and vein with subsequent removal of the spleen.

However, in the presence of peripancreatic inflammatory infiltrate, due to the flow of destructive pancreatitis, any available laparotomic access to the gastro-splenic and pancreatic-splenic cords is extremely difficult for the surgeon and traumatic for the patient. Impractical seems laparotomy and when a patient with pancreatic abscess of the spleen, there are some positive trends in the treatment of peripancreatic lesions destruction percutaneous minimally invasive methods, and the latter is increasingly used in the last decade. You should not neglect also the occurrence of fulminant sepsis after splenectomy the Finance through the bed of the resected ribs above the zone of localization of abscess after diagnostic puncture and confident of obtaining pus (C. I. Filin, A. L. Kostyuchenko. Emergency pancreatology. -S.-Petersburg, 1994).

The disadvantages of this organ-preserving method are its invasiveness, risk of developing pleural, pulmonary complications due to the proximity of purulent and significant limitations of the respiratory excursions of the chest.

The development of precision technology percutaneous drainage of abdominal pathological lesions under ultrasound, x-ray television and intercomputer control has led to a revision of the indications for laparotomy with limited liquid accumulations in the liver, the pancreas, the various divisions of the abdominal cavity (Y. A. Nesterenko, S., shapovalianz, S. C. Mihalyov, M. R. Imanaliev. Echotomography in the diagnosis and treatment of acute pancreatitis.- M , 1995; A. N. Lots, I. I. a), G. H. Musaev et al. Destructive forms of pancreatitis: status and future challenges // minimally Invasive interventions in surgery. M., 1996. C. 221-226; B. S. Briskin, A. M. Minasian, M. A. Vasiliev, M., Barsukov. Percutaneous minimally invasive interventions under the control of sonography in abscesses of the abdominal cavity // minimally Invasive interventions in surgery.- M., 1996. C. 208-211).

For the prototype declared sposored control of the ultrasonic scan. (Janssen-J; Johanns-W; Greiner-L Non-operative management of pancreatitis with splenic involvement // Z Gastroenterol. , 1997 Aug; 35(8): 621-5). Treatment method in this method is the following: after diagnostic ultrasound produce local anesthesia and sighting fine-needle puncture of the pseudocyst with simultaneous aspiration.

However, this method is acceptable only when uninfected pseudocyst, not containing large fragments of tissue debris, blood clots.

The purpose of the invention is to reduce mortality in patients with destructive forms of pancreatitis, accompanied by the formation of infected pancreatic pseudocyst of the spleen.

The task of the invention is to speed up the process of restitution of pancreatic lesions destruction by eliminating pancreatic abscess of the spleen percutaneous access with minimal trauma to the patient and to reduce the likelihood of fatal complications, frequent at the traditional methods of surgical treatment of these patients.

The essence of the method lies in the fact that the removal of tissue debris, preserving unchanged parenchyma and subsequent reorganization of the abscess cavity is the first channel, used in future to conduct drainage catheter is located in the intercostal space on the anterior or sredneoblastnoy line depending on the constitutional features of the patient, size of the spleen and localization of the nidus in it. Consider acceptable, if topographic-anatomical features not otherwise allow the carrying out of drainage catheter through the rib-diaphragmatic sinus at its lowest point.

The method is performed in the following sequential actions. Patient is placed on the right side, creating a stable position with a roller under the back and rump. Perform intravenous anesthesia. After processing the surgical field during an ultrasound scan of the intercostal spaces on the left selects the trajectory of the needle channel; it must be on the shortest path from the skin to the abscess and not intersect the rib-diaphragmatic sinus. However, the latter condition is relative, as our experience shows. Under ultrasound guidance into the cavity of the abscess is injected on the upper edge of the underlying ribs puncture needle with a diameter of 1.0 to 1.5 mm, aspirinum 10-20 ml content, the needle is injected angiographic conductor, p is th cavity, it is especially important to consider in the event of involuntary conduct of the catheter through the pleural sinus. The catheter aspiritual contents and wash out the cavity of the abscess solutions antiseptical under ultrasound control, confirming the correct location of the catheter and the absence of any bleeding. In the event of a catheter through the pleural sinus, the catheter is injected 40-50% solution of radiopaque substances under x-ray television control to ensure the absence of getting the contents of an abscess in the free pleural cavity. In the future perform fractional irrigation of the abscess cavity with antiseptic solution through the catheter. Completeness of restoration and the process of reduction of necrotic cavity in the spleen track when fistulografii.

A distinctive feature of this method of treatment of pancreatic abscess and pancreatic pseudocyst of the spleen is the use of the drainage system, conducted by puncture channel in the intercostal space, which allows without laparotomy, with preservation of the parenchyma of the spleen to carry out reorganization of the nidus.

Quickly achieved positive clinical effect remains spleen, sokrawenija in the Department of surgical leczenie pancreas Republican center for functional surgical gastroenterology, 26.06.98 Upon receipt complained of pain in the upper abdomen, recurrent vomiting, increased body temperature to febrile digits. Sick with 14.05.98, about suppurative complications of acute destructive pancreatitis was operated with external drainage stuffing bags and outer cholecystectomia. Admission is palpated in the epigastrium infiltrate 6X10 cm, in the right hypochondrium - fistulous opening with bile discharge, in the left hypochondrium - fistulous opening with purulent discharge. Ultrasonography revealed the presence of a liquid cavity under the capsule of the spleen on its outer surface dimensions HH cm with heterogeneous echogenicity content. 27.06.98, under intravenous anesthesia after sighting the puncture in the 10th intercostal space in peredatochnoi line during ultrasonic testing of installed catheter. The patient was treated with discrete washing the cavity with antiseptic solutions with sonographic monitoring of its condition and size. After 18 days after the inspection fistulography that upheld the restitution of the cavity, and in the absence of a detachable catheter was removed. The patient was discharged in satisfactory condition 20.07.98, When the control ultrasonic Isleta of the proposed method is expected to reduce the incidence of septic complications in patients with destructive pancreatitis in the prevention laparotomy about the infected pancreatic pseudocyst of the spleen and to reduce mortality in this group of patients.

The method of surgical treatment of infected pancreatic a pancreatic pseudocyst of the spleen, including the removal of necrotic content with preservation of the parenchyma of the spleen under the control of the ultrasonic tomography, characterized in that the removal of necrotic content is performed by percutaneous drainage by needle channel in the intercostal space, corresponding to the lesion.

 

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