Method for prevention of developing acute postoperative pancreatitis accompanying endoscopic transpapillary interventions

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely anesthesiology, intensive therapy and endosurgery, and may be used in patients in need of endoscopic transpapillary intervention. That is ensured by an intravenous infusion therapy with crystalloid solutions in the amount of 800-1200 ml. An epidural space is punctured and catheterised at the level of Th VIII - Th IX with the catheter moved by 4-5 cm in the cranial direction. A local anaesthetic solution and Clopheline 100 mcg are introduced through the epidural catheter at the level of Th V - Th X 20 minutes before the endoscopic transpapillary intervention. It is followed by pre-medication enabled by introducing 0.1% atropine 0.5-1 ml and 0.5% relanium 1-2 ml, and the patient is wheeled into a catheterisation laboratory. After the endoscopic transpapillary intervention completed, the patient is transferred into an intensive therapy unit wherein prolonged epidural analgesia is enabled by introducing 0.5-1% lidocaine 10 ml into the epidural space every 4 hours. If observing no clinical manifestations of postoperative pancreatitis, the epidural catheter is removed, and the patient is transferred into a department of surgery for symptomatic treatment.

EFFECT: method enables preventing acute postoperative pancreatitis following such interventions due to action of a general mechanism of pathogenesis of the given pathology.

1 ex

 

The invention relates to medicine, in particular for endosurgery, and for the prevention of acute postoperative pancreatitis during endoscopic transpapillary interventions in patients with syndrome of biliary hypertension.

Endoscopic transpapillary intervention (ATPV), which include endoscopic papillosphincterotomy, balloon hidrografia large duodenal papilla, nasobiliary drainage, replacement of the common bile and pancreatic ducts, retrograde cholangiopancreatography and others, are widely used in the treatment of syndrome of biliary hypertension. The most common complication of these interventions in the early postoperative period is acute pancreatitis.

The overall incidence of acute postoperative pancreatitis after performing ATPV, according to various authors, ranging from 8.7% to 42,3% [1, 2, 3], and pancreonecrosis 0.3%-2,6% of cases [1, 2], the mortality in the development of these complications reaches 25%-80%.

There is a way to prevent acute postoperative pancreatitis during endoscopic transpapillary interventions, including perioperative use of various drugs: drugs that reduce exocrine activity of the pancreas (somatostatin), improve the existing motor function of the intestine (prokinetic, the cholinomimetic agents), non-hormonal anti-inflammatory drugs, heparin and others (prototype).

The disadvantages of this method are the low efficiency in patients with high risk of developing this complication and high cost of these medicines.

The well-known second method of prevention, where the final stage of the operation, to eliminate the trigger of acute pancreatitis is increasing hydrostatic pressure in the ducts of the pancreas, establish stent (drainage) in the common pancreatic duct.

The disadvantages of this method are its low efficiency, the need for repeat endoscopic intervention in a few days to remove the stent, the high cost of consumables.

The technical result of the claimed method is to improve the prevention of acute pancreatitis after endoscopic transpapillary interventions.

The technical result is achieved in that the method of preventing the development of acute pancreatitis after endoscopic transpapillary interventions, including the use of epidural analgesia, the purpose of which, after a moderate intravenous infusion therapy in the amount of 800-1200 ml crystalloid solutions, the dotted line and the Catete is rezerwat epidural space at the level of Th VIII - Th IX, the catheter promote 4-5 cm in the cranial direction, 20 minutes before the expected endoscopic manipulation, to achieve sensory and sympathetic blocks at the level of Th V Th X through an epidural catheter is injected solution ropivacaine 0,4% - 10-12 ml, or a solution of bupivacaine and 0.2% - 10-12 ml lidocaine 1% - 10-12 ml solution marcaine 0,2% - 10-12 ml and the solution clonidine 100 mcg, after sedation with the use of a solution of atropine 0.1% to 0.5-1 ml of a solution Relanium a 0.5% 1-2 ml of the patient served in the x-ray operating for endoscopic transpapillary intervention, and after endoscopic transpapillary intervention the patient is transferred to the intensive care unit, where they extended epidural analgesia is injected into the epidural space for every 4 hours of lidocaine 0.5% and 1% 10 ml, and then, in the absence of clinical manifestations of postoperative pancreatitis, remove the epidural catheter and the patient is transferred to the Department of surgery for symptomatic treatment.

The essence of the proposed method.

Improving the efficiency of prevention of acute pancreatitis after endoscopic transpapillary interventions is achieved by perioperative use of epidural analgesia.

During the prospective study in the City Who Have higher professional education "Volgograd state medical University Clinic No. 1 in 2008-2010, it is proved that the use of epidural analgesia, compared to "traditional" treatment using drugs that reduce exocrine activity of the pancreas (somatostatin), which improves motor function of the intestine (prokinetic, cholinomimetic agents), non-hormonal anti-inflammatory drugs, has led to a reduction in the incidence of acute pancreatitis after endoscopic transpapillary interventions more than seven times (from 22.1% to 3.0%).

When using the inventive method offers the possibility of effective prevention in patients at high risk of developing this complication.

Methodology the proposed method.

The method is as follows. Before endoscopic transpapillary interventions patients are admitted to the intensive care unit, where, after a moderate intravenous infusion therapy in the amount of 800-1200 ml crystalloid solutions, the dotted line and kateteriziruyut epidural space at the level of Th VIII - IX Th, catheter promote 4-5 cm in the cranial direction, 20 minutes before the expected endoscopic manipulation, to achieve sensory and sympathetic blocks at the level of Th V Th X through an epidural catheter is injected solution ropivacaine 0,4% - 10-12 ml or solution of bupivacaine and 0.2% - 10-12 ml lidocaine 1% - 10-12 ml solution marcaine 02% - 10-12 ml and the solution clonidine 100 mcg, after sedation with the use of a solution of atropine 0.1% to 0.5-1 ml of a solution Relanium a 0.5% 1-2 ml of the patient served in the x-ray operating for endoscopic transpapillary intervention, and after endoscopic transpapillary intervention the patient is transferred to the intensive care unit, where they extended epidural analgesia is injected into the epidural space for every 4 hours of lidocaine 0.5% and 1% 10 ml, and then, in the absence of clinical manifestations of postoperative pancreatitis, remove the epidural catheter and the patient is transferred to the Department of surgery for symptomatic treatment.

An example of a specific implementation.

Example.

Zudina ETC., 56 years history No. 4476, was admitted to the surgical Department of the hospital №1 Wagga 05.11.09, with a diagnosis of post-cholecystectomy syndrome. Choledocholithiasis. Obstructive jaundice. 06.11.09 was made urgent endoscopic papillosphincterotomy with instrumental revision and readjustment of the choledochus, nasobiliary drainage.

As anesthesia and method of preventing the development of acute pancreatitis was used epidural analgesia.

The Protocol epidural analgesia.

Infusion therapy: aq NaCl 0,9% - 400 ml, aq Glucose 5% - 400 ml.

In opticheskih conditions, under local anesthesia Sol. Lidocaini 2% - 2 ml, at the level of Th VIII - IX Th produced puncture and catheterization of the epidural space, the catheter is pulled to 5 cm in the cranial direction, the suction test is negative, put a test dose of Sol. Lidocaini 2% to 4 ml, 15 min signs of intrathecal injection of anesthetic no. Aseptic dressing, catheter fixed with adhesive tape.

After carrying out the suction of the sample entered the main dose: Sol. Marcaini 0,2% - 12 ml, Sol. Klofelini 0,01% - 1 ml in 15 min: sensory block level V Th - Th XI, sympathetic block - IV Th - Th XII.

Breathing independent, adequate, stable hemodynamics, HELL 125/65 mm Hg, PS 67 1 min, rhythmic.

With sedation/entered: Sol. Atropini of 0.1% to 0.6 ml, Sol. Relanii 0,5% - 1 ml the Patient is transported in the x-ray operating room.

Protocol operations No. 48(4476).

In the stomach - the picture is mixed gastritis. The mucosa of the duodenal bulb edematous, hyperemic. Large duodenal papilla significantly pronounced swollen, the mouth up to 4 mm with scalloped edges, covered with fibrin. From the mouth comes purulent bile. Canulate to 60 mm Retrograde cholangiography: shadow of the choledochus expanded to 12 mm, with angular deformity in the middle third, a filling defect in the terminal division of the choledochus. Endoscopic papillosphincterotomy to 18 mm In instrumental revision, CA the purpose of the choledochus received cholesterol "putty". Control cholangiography: shadow of the choledochus homogeneous, evacuation of contrast in the intestine rapidly. Installed nasobiliary drainage.

Diagnosis: post-cholecystectomy syndrome. Choledocholithiasis. Obstructive jaundice. Cholangitis.

In the postoperative period was held conservative therapy, prolonged epidural analgesia. 6 hours after manipulation removed the catheter from the epidural space, the patient was transferred from intensive care to the surgical Department. Within 2 days of normal laboratory values, disappeared clinical signs of cholangitis. When the control ultrasound data for the presence of free fluid in the abdominal cavity is not revealed. Discharged on the 8th day in a satisfactory condition.

Advantages, the positive effect of the claimed method:

- The effectiveness of the inventive method is several times the efficiency of all known ways of preventing the development of acute pancreatitis after ATPV.

- Versatile: effective in patients with high risk of developing this complication.

- Safe: the risk of developing complications from catheterization of the epidural space 100 times lower risk of acute pancreatitis with ATPV and these complications are not life-threatening.

- The claimed method is not only effective method of preventing the development of astrooptica, but also an adequate method of pain relief.

Compared with other methods do not require significant expenses.

It should be noted that the application of the inventive method for endoscopic transpapillary intervention leads to a reduction in the incidence of acute postoperative pancreatitis. However, reducing the relative risk of developing this complication is to 86.3%. The reduction in the absolute risk of acute postoperative pancreatitis is 19,1%.

References

1. Malyarchuk V.I. Fedorov, A.G., SERGIY Davydov and other Factors affecting the results of endoscopic transpapillary interventions in patients with choledocholithiasis and stenosis of the major duodenal papilla. // Endoscopic surgery - 2005. Volume 11, No. 2. - P.30-39.

2. The Revyakin V., Klimov PV, Ibragimov NI and other Complications and mortality after endoscopic papillosphincterotomy: experience 1,300 operations. Russian Symposium "Intraluminal endoscopic surgery: book of abstracts edited by Prof. Wigoltingen. M, 1998; 67-69.

3. Andriulli A, Leandro G, Niro G, et al. Pharmacologic treatment can prevent pancreatic injury after ERCP: a meta-analysis // Gastrointest Endosc. 2000; 51: 1-7.

A method of preventing the development of acute postoperative pancreatitis during endoscopic transpapillary interventions, characterized in that use e duralloy analgesia, the purpose for which, after reasonable intravenous infusion therapy in the amount of 800-1200 ml crystalloid solutions, the dotted line and kateteriziruyut epidural space at the level of Th VIII - IX Th, catheter promote 4-5 cm in the cranial direction, for 20 min prior to the proposed endoscopic manipulation, to achieve sensory and sympathetic blocks at the level of Th V Th X through an epidural catheter is injected solution ropivacaine 0,4% - 10-12 ml or solution of bupivacaine and 0.2% - 10-12 ml lidocaine 1% - 10-12 ml solution marcaine 0,2% - 10-12 ml and the solution clonidine 100 mcg, after sedation with the use of a solution of atropine 0.1% to 0.5-1 ml of a solution Relanium a 0.5% 1-2 ml of the patient served in the x-ray operating for endoscopic transpapillary intervention, and after endoscopic transpapillary intervention the patient is transferred to the intensive care unit, where they extended epidural analgesia is injected into the epidural space every 4 hours of lidocaine 0.5% and 1% 10 ml, and then in the absence of clinical manifestations of postoperative pancreatitis remove the epidural catheter and the patient is transferred to the Department of surgery for symptomatic treatment.



 

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