The method of surgical treatment of a pancreatic pseudocyst of the pancreas

 

(57) Abstract:

The invention relates to medicine, surgery may be used in the surgical treatment of pancreatic pseudocyst of the pancreas. Execute access to the "mediastinum" retroperitoneum. The puncture is carried out in the area of the rib-muscle angle to the left. When advancing the needle perform Gidropark tissues. After the puncture, drain the pancreatic pseudocyst. The method can reduce the mortality in the treatment of retroperitoneal pancreatic a pancreatic pseudocyst. 2 Il.

The present invention relates to medicine, namely to surgery, and can be used in the treatment of a pancreatic pseudocyst of the pancreas localized in the region of the body, tail and retroperitoneal cellular tissue space on the left.

An increase in the frequency of cases the diagnosis of a pancreatic pseudocyst due to destructive processes in the pancreas, associated, first, with success in the treatment of severe forms of acute pancreatitis and, secondly, with the introduction of the General practice sophisticated imaging techniques (sonography, x-ray and magnetic resonance tomography). When destructive form of acute pancreatitis education pancreatic pseudocyst is observed in 50-55% of cases (Grace R. A. spleen, the splenic angle of the colon, the upper pole of the kidney (owl Century. And. , Kostyuchenko A. L. Emergency pancreatology. - S.-Petersburg, 1994).

It is known that in the unformed wall of the pseudocyst and no tendency to spontaneous reduction, apply the following methods of operation: 1) external drainage, including laparotomy, opening the cyst, the revision of the cavity, the establishment of the drainage system (Corigin A. A., Nechaev E. A., Smirnov, A. D. Surgical treatment of cysts of the pancreas, - S. Petersburg, 1996); 2) minimally invasive percutaneous drainage, including puncture and holding catheters under ultrasound and x-ray television control with subsequent readjustment of the 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. Musayev and other 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 chirurgiens access and even more so when laparotomy may get infected content from abnormal retroperitoneal concentrations in the free abdominal cavity with subsequent development of peritonitis.

As the prototype is taken treatment of cysts of the pancreas, including puncture, contrast and drainage under ultrasound and x-ray control by means of transluminal access point located in the region of the left triangle Lesgaft-Grunfeld on the level of the first lumbar vertebra. In this way the drainage device spend ventral 0.5 - 2.0 cm outwards from the side surface of the vertebra (Pogrebnyakov C. Y., Lobanov S. L. Patent of the Russian Federation, MKI A 61 B 17/00 N 2098145).

However, along with the indisputable advantages (extraperitoneal conducting catheter exception of injury to the kidneys, aorta, celiac plexus) method, in our opinion, has several disadvantages: a small angle between the extreme positions a puncture needle, limited to one side of the transverse process of the vertebra and on the other hand kidney, not to drain not formed a pseudocyst with localization in parabolicsar and parrinello tile shall I puncture needle along the vertebral body; acoustic shadow from the transverse processes of the vertebrae difficult ultrasonic visualization; due to the severity of the condition is not always the patient may take the position lying on his stomach; the catheter is fixed to the skin on the back that is not comfortable for the patient during long-term treatment.

The aim of the invention is to improve the treatment results of patients with destructive pancreatitis, reducing mortality in these patients.

Task: without risk of damage to the spleen, kidney, splenic angle of the colon to get the opportunity extraperitoneal access for percutaneous drainage of retroperitoneal pancreatic a pancreatic pseudocyst under echographic control.

The essence of the method lies in the fact that remove tissue debris and subsequent cavity sanation a pseudocyst is performed by percutaneous drainage under ultrasound and x-ray television control. When this needle channel used in future to conduct drainage catheter is formed in the left rib-muscle angle between the XII rib and the outer margin of the Sacro-spinalis muscles), and dorsal Caudalie from the lower pole of the spleen and dorsal and cranial from vetsa pancreatic pseudocyst, due to the destructive process in the pancreas and the structural features of the lateral wall of the fiber space, where a relatively thin fascia contributes to the spread of the inflammatory process upwards, downwards and outwards (Korte, 1923).

The method is as follows. The patient laid on the floor right side, giving a stable position by the platen beneath the lumbar region. Produce intravenous anesthesia. The ultrasonic sensor is installed in the region of the rib-muscle angle and choose the angle of the needle, which needle track passes between the lower pole of the spleen and the upper pole of the kidney, and the movement of the needle 1-2 mm in diameter is controlled by ultrasound. To avoid damage to the organs located in the immediate vicinity laid needle track during the advance of the needle, apply Gidropark tissues (e.g. 0.25% solution of novocaine) that keep track of sonography. After insertion of the needle into the cavity of a pseudocyst aspiritual its contents in this volume, to reduce the pressure in the cavity up to 200-250 mm of a water column, then fill the cavity with water-soluble contrast medium induced by the drug (for example, 40-50% of the unaudited hold the string of Lundequist, the direction of holding the strings regulate the inclination of the needle and control radiographically. The string can be positioned in various ways: by the tail and body of the pancreas, in front of perirenal or rear parabolicheskoi fiber space. The string in the specified direction down the catheter, the diameter and length of the perforated end of the target individually. Drainage is carried out or fractional permanent irrigation zone of destruction antiseptic solution.

The main distinctive feature of the proposed method in the new access, allowing to drain from one position parametron, parabolon and actually retroperitoneal tissue or "mediastinum" retroperitoneum (N.And. Pirogov). Injuries located in the immediate vicinity of the puncture channel solid and hollow organs warn constant ultrasonic visual control over the movement of the needle and the receiving layer exocontralto getroproperty be in the direction of needle tissue.

Example. Patient P., aged 47, N history of 1597. He enrolled in the Department of surgery of the liver and pancreas of the Republican centre for functional surgery is an increase of 38 days, ill acutely, the cause of the disease with nothing to link. Was hospitalized to the Central district hospital where diagnosed diabetes mellitus, and then transferred to the Republican Oncology center to clarify the nature of a lesion in the left upper quadrant, where a CT scan revealed "space-destructive process of the pancreatic tail" When entering RZQHG in the left upper quadrant is palpated painful, dense formation size 610 cm, spleen enlarged. Ultrasound revealed a liquid, the formation of irregular shape 10117 cm, with thin walls, heterogeneous echogenicity content located in the retroperitoneal space, between the kidney, enlarged spleen, the stomach and the splenic angle of the colon. 29.11.96 made drainage of a pseudocyst extraperitoneal access needle track selected when the sonogram, between the upper pole of the kidney and splenic angle poperechnopolostah intestine, with hydropiperoides tissues with 0.5% solution of novocaine, with x-ray television control installation of the catheter. Aspirated 400 ml of hemorrhagic detachable fabric detritus, with amylolytic activity 379,9 g/l/h, without signs of inficon is possessed; continued treatment on an outpatient basis. After 15 days in the control fistulografii identified plagiogranites numb in parallon, under x-ray television control carried out, the location of the working end of the catheter. 15.01.97 catheter removed, ultrasound signs of cysts in the pancreas was not detected (see Fig. 2). After 6 months the patient has no complaints, in the abdominal cavity revealed no pathology.

When using the proposed method is expected to decrease the development of septic complications and mortality in patients with pancreatic pseudocyst by preventing laparotomy.

The method of surgical treatment of a pancreatic pseudocyst of the pancreas, including puncture extraperitoneal access and drainage, characterized in that to provide access to the "mediastinum" retroperitoneum, fiber space parabolon and/or parametron, the puncture is carried out in the area of the rib-muscle angle to the left, and at the same time, when the movement of the needle, perform Gidropark tissues.

 

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