Method of treating pancreatonecrosis

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used in treating patients with pancreatonecrosis. For this purpose, opening the omental sac and performing the pancreatic gland abdomination along a lower edge of its body and tail are followed by puncturing retroperitoneal fat with introducing components No.1 and No.2 therein. First, component No.1 consisting of dry lyophilized cryoprecipitate 50-70 g dissolved in normal saline 100 ml is slowly administered. Then 10 minutes later, the retroperitoneal fat is additionally punctured, and component No.2 consisting of NIH sterile thrombin dissolved in 5% s-aminocapronic acid 10 ml is introduced. An artificial fibrin barrier is formed in the retroperitoneal fat 5-7 minutes later by mixing and polymerising the two solutions.

EFFECT: method provides the effective treatment of pancreatonecrosis by forming the artificial fibrin barrier on the way of a potential impregnation of the retroperitoneal fat in an enzymatic fluid.

3 dwg, 2 ex

 

The invention relates to medicine, namely to surgery, and can be used for the treatment of patients with pancreatic necrosis.

Despite the progress made in the improvement of surgical treatment of pancreatic necrosis with the introduction of mini-invasive and video endoscopic methods, the overall case fatality rate for 30-40 years remains unchanged and is 3.9-26%, with infected pancreatic necrosis mortality is 85%, and in patients with fulminant its over - 100%.

There is a method of treatment of pancreatic necrosis with the use of cryosurgery for pancreatic cancer, and in the presence of parapancreatic - its crioestaminal [B. I. Alperovich, Merzlikin, NV, Portnyagin BTW, Cryosurgery and abdominal pancreas in acute destructive pancreatitis // Surgery. - 1989. No. 1. - P.98 - 101]. According to the authors, the application of a known method cryotechnologies reduces postoperative mortality in pancreatic necrosis up to 9.5-11.1 per cent.

The disadvantage of this method is low efficiency and the occurrence of complications due to the lack of control of the depth of freezing tissues, additional damage to the capsule and parenchyma of the pancreas as a result of cryosurgery and cryonecrosis, the risk of developing pancreatic fistula and bleeding, suppuration necrotic cryostructure, cold tra what we receptacles supplying the pancreas.

The closest achieved technical result (prototype) is a method of treatment of pancreatic necrosis by isolating retroperitoneal tissue when abdominal pancreas [V.A. Kozlov, V. Starodubov Abdominal pancreas, bursoomentoscopy and local hypothermia in the treatment of acute pancreatitis. - Sverdlovsk: Publishing house of the Ural University, 1988, 160 C.]. The known method consists in the dissection of the peritoneum over the bottom and top edge in the body and tail of the body, followed by separation of the pancreas from retroperitoneal peripancreatic fiber from neck to tail, realizing thereby moving it from the retroperitoneum into the abdominal cavity. This phase of the operation is aimed at decompression parapancreatic fiber, adequate evacuation pancreatic and infected toxic effusion. Further to the pancreas fail drainages different designs.

The disadvantages of this method are: 1. Increased trauma and bleeding tissue by mechanical selection gland of the fiber. 2. Destruction peripancreatic vascular, nervous and lymphatic structures. 3. No barrier between the gland and retroperitoneal tissue with their simple mechanical separation. 4. In cases where p is dodania seal the possibility of infection and necrosis. 5. The penetration of infection in the retroperitoneal tissue through gauze swabs. All this leads to inefficient use of the known method.

The technical result of the proposed method is to increase efficiency by forming artificial fibrin barrier to the spread of enzymatic soaking retroperitoneal tissue in patients with pancreatic necrosis.

The technical result is achieved by the fact that after opening the stuffing bags and abdominal pancreas along the lower edge of its body and tail produce puncture retroperitoneal tissue, which slowly introducing a two-part composition: component No. 1, consisting of dissolved in 100 ml of physiological solution 50-70 grams of dry lyophilized to cryoprecipitate, and after 10 minutes introduce a component No. 2, consisting of dissolved in 10 ml of 5% solution of ε-aminocaproic acid 150 units NIH sterile thrombin, and after 5-7 minutes after mixing and polymerization of the two solutions form in the retroperitoneal tissue artificial fibrin barrier.

The authors propose an effective method for the treatment of pancreatic necrosis due to the formation along the lower contour of the body and tail of the pancreas artificial fibrin barrier by mixing in the retroperitoneal tissue two-component composition.

The process is carried out after the respective way.

The method is illustrated by figures 1-3.

The figure 1 presents the puncture retroperitoneal tissue at the level of the lower edge of the body and tail of the pancreas.

The figure 2 presents an introduction to the retroperitoneal tissue component No. 1, consisting of dissolved in 100 ml of physiological solution 50-70 grams of dry lyophilized to cryoprecipitate (production Altai regional station of blood transfusion)containing fibrinogen and other adhesive proteins in blood plasma.

The figure 3 presents additional puncture and adding in the retroperitoneal tissue, with distributed it component No. 1, component No. 2, consisting of dissolved in 10 ml of 5% solution of ε-aminocaproic acid 150 IU NIH sterile thrombin.

The position marked on the figures 1, 2, 3, denote: 1, liver; 2 - pancreas; 3 colon, 4 - spleen; 5 - retroperitoneal tissue; 6 - component No. 1, consisting of dissolved in 100 ml of physiological solution 50-70 grams of dry lyophilized to cryoprecipitate; 7 - component No. 2, consisting of dissolved in 10 ml of 5% ε-aminocaproic acid 150 units NIH sterile thrombin; 8 - formation in the retroperitoneal tissue artificial fibrin barrier.

After performing laparotomy evacuated enzyme effusion from all parts of the abdominal cavity, and then produce the opening of the gland is howling bags, carry out an audit of the pancreas and assess the severity of pancreatic necrosis, the degree of lesion of retroperitoneum. Then dissect the peritoneum on the upper and lower edges in the body and tail of the pancreas. Form fibrin block at the level of the lower edge of the body and tail of the pancreas. To do this simultaneously in the preoperative prepare component No. 1, by dissolving in 100 ml of physiological solution 50-70 grams of dry lyophilized to cryoprecipitate (for example, production of the Altai regional station of blood transfusion)containing fibrinogen, factor XIII, fibronectin and other adhesive proteins in blood plasma. Avoid bloodborne infections in the harvesting of dry cryoprecipitate used karantinirovanija plasma donors. Then get component No. 2 by dissolving 150 units NIH sterile thrombin in 10 ml of 5% ε-aminocaproic acid. Thrombin is a sterile protein product obtained from karantinirovaniya of human blood plasma. Make puncture retroperitoneal tissue along the bottom edge of the body and tail of the pancreas and in her first slowly introducing 100 ml of a solution component No. 1. After distribution of the solution in the retroperitoneal tissue after 10 minutes produce repeated puncture and further added 10 ml of a solution component is 2. By mixing and polymerization of the two solutions after 5-7 minutes in the retroperitoneal tissue is formed artificial fibrin barrier preventing the spread of enzyme effusion in the retroperitoneal tissue and the formation of parapancreatic and prikolnoe phlegmon.

Clinical examples

Example 1. Patient M., 25, enlisted in the 1st surgical Department CGBOT "City hospital №1" 26.02.2012, complaining of severe pains, localized in the epigastric region, nausea, dry mouth, malaise. Ill for about 2 hours. Before within a few days of taking alcohol in large quantities. The attack developed after receiving repeated servings of alcohol. Delivered to the Department by the ambulance service. Objectively: General condition is regarded as moderate. Tongue dry, lined with a whitish bloom. The abdomen is not swollen, actively participates in the act of breathing. On palpation there is a pronounced soreness and tension of the muscles of the anterior abdominal wall in the epigastric region. Pathological lesions in the abdominal cavity is not palpated. The pulsation of the abdominal aorta in the epigastric region is sharply attenuated positive symptom resurrection). In sloping areas of the abdomen are signs of free fluid. 26.02.2012, performed the ultrasound examination of the abdominal organs: the pancreas is increased in RA the measures (the head - 32 mm, body - 25 mm), its echogenicity is reduced, echostructure grainy, fuzzy contours and uneven. On the anterior surface of the gland traces of free fluid. Conclusion: the increasing size, diffusely heterogeneous changes in the structure of the pancreas, the free liquid in the packing bag. 26.02.2012 Guyanese videolaparoscopy: abdominal moderate amount of hemorrhagic effusion. In the projection of the pancreas, the stomach and lesser omentum dramatically wibaut. There is marked swelling of the fiber, it gemorragicheskii imbibery. The loops of the small intestine moderately poduce. Conclusion: hemorrhagic pancreatic necrosis. 26.02.2012 was performed MDCT of the Pancreas is enlarged, the contours of her fuzzy, the structure of the parenchyma is heterogeneous with hypotensive inclusions, Virunga duct is not expanded. Parapancreatic fiber infiltrated with the distribution of infiltration to the left and down to the left kidney. In the omental pouch - free liquid. In the pelvis is a large amount of fluid in the pleural cavity left traces of liquid. Conclusion: pancreatic necrosis, peripancreatic infiltrate, free fluid in the abdominal cavity. Reactive pleural effusion on the left. Laboratory data: amylase blood - 1657 U/l, leucocytes - 16,7 p/I shift left - 21, toxigenic grainy ++, hemoglobin - 167 g/l, blood sugar - 8 mmol/L. Take the traveler conservative drug therapy (infusion therapy, antispasmodics, antibiotics, octreotide) is ineffective. 28.02.2012, - videolaparoscopy: abdominal a large number muddy hemorrhagic exudate, blood peritoneum, bloated loops of the small intestine. On the gland, parietal peritoneum multiple plaques of stefanakos. Retroperitoneal tissue richly impregnated dirty hemorrhagic exudate. Will wybodaeth the stomach, the gastrohepatic omentum. Conclusion - infected pancreatic necrosis, retroperitoneal abscess. It was decided to hold the conversion of intervention in open surgery. Surgery: laparotomy, abdominal pancreas, drainage of peripancreatic fiber stuffing bags and subhepatic space multiple tubes. In the abdominal cavity 600-700 ml of hemorrhagic exudate (taken sowing and research on hemostasis and enzyme activity). Multiple foci of plaques Theotokos on the omentum, and retroperitoneal tissue, mesentery mesocolon. Fabric abundantly infiltrated hemorrhagic content. Cut the gastrocolic ligament, opened the packing bag. The pancreas is enlarged, dense, purple-gray color all over. Parapancreatic fiber richly impregnated dirty hemorrhagic content with plaques of stationers. The parietal peritoneum is dissected by the upper and lower contacts the frame along gland, stood out a large number of dull-hemorrhagic exudate. Revealed retroperitoneal abscess on the left and on the right, stood out more than 500 ml of a turbid hemorrhagic effusion. Selected pancreas. With the aim of creating a restrictive barrier to the spread of cellulitis in the retroperitoneal tissue along the lower edge of the pancreas by puncturing introduced 100 ml of component No. 1 dissolved in 100 ml of physiological solution, 50 grams of dry lyophilized to cryoprecipitate production of the Altai regional station of blood transfusion. Then, after 10 minutes, created in the tissue infiltration puncture and aspiration introduced component No. 2, consisting of dissolved in 10 ml 5% 8-aminocaproic acid 150 units NIH sterile thrombin. After 7 minutes in the retroperitoneal tissue was formed artificial fibrin barrier. The retroperitoneal space is drained to the left and to the right through contraditory in the lumbar regions. In the packing bag introduced 4 drainage tube placed through the middle of the wound. Laparotomic wound tightly sewn. Diagnosis: Total hemorrhagic pancreatic necrosis, peripancreatic infiltrate beginning abscess retroperitoneal tissue left and right. In the postoperative period were treated for 5 days in the ICU. The state remained heavy stable. The floor is chal intensive infusion therapy. The drainage of the retroperitoneal tissue serous hemorrhagic discharge. In the first 1-2 days - very rich, and on the 6-7 day - scanty serous in nature. Daily twice a day cristinana sanitation zone of infection with chlorhexidine. Body temperature within 3-4 days high (37,5 -38,2 C), normalized to the 7-8 day postoperative period. Was discharged in good condition.

Example 2. Patient L., aged 27, arrived in 1 surgical Department CGBOT "City hospital №1" 3.02.2012 by ambulance complaining of intense pain in the upper abdomen. Ill for about 18 hours. Pain intensified gradually developed nausea, multiple bringing relief to the vomiting. Eve took alcohol. At objective inspection: a state of moderate severity. Tachycardia - 95 in 1 min, AD - 11070 mmHg Abdomen moderately poddut, more in the upper half. There is a pronounced muscles of the anterior abdominal wall, mainly in the epigastric region. The pulsation of the abdominal aorta in this area is greatly weakened. Clearly infiltration is not palpated. Intestinal peristalsis is weakened. Laboratory data: a-amyl blood -12954 U/l, bilirubin blood - 14 mmol/l, blood sugar - 3.2 mmol/l, leukocytosis and 14.6×103and stab shift - 7. Ultrasound examination of abdominal cavity organs at receipt: liver, gall bladder the e changed. The wall of the gallbladder and bile ducts smooth, not changed. Pancreas lazerette only in fragments. The size of her body - 16 mm, echostructure saved, the external contours equal, precise. MSCT (4.02.2012,): the pancreas was significantly increased in size, around the glands infiltrate extending into the retroperitoneal tissue right above the dome of the diaphragm a small amount of free fluid. The diagnosis of pancreatic necrosis, infiltration of the retroperitoneal tissue, more to the right. During the first 3 days received intensive conservative therapy: Antibacterials, analgesics, antispasmodics, infusion therapy. The pain has been significantly cropped, however, there were signs of toxemia. Still even royalty infiltrate in the epigastric region, weakness, malaise, tachycardia. 6.02.2012, (3 day) the patient underwent laparotomy, a revision of the abdominal cavity in the free abdominal cavity to 300 ml of yellowish transparent effusion (taken on the study of the activity of enzymes and hemostasis). In the area of the gastrocolic ligament, retroperitoneal tissue left and right abundant enzyme-hemorrhagic saturation, omentum single plaques of stefanakos. The most pronounced destructive changes in the right half of the abdomen, in the area of the head POG lodochnoy cancer. In the avascular zone dissected the gastrocolic ligament and opened the packing bag. Revision: the pancreas is enlarged in the area of the body, intensely colored in purple color, retroperitoneal tissue infiltration. Diagnosis: Sterile Subtotal pancreatic necrosis, lesions mainly body and head glands, mixed shape, enzymatic peritonitis, massive enzymatic-hemorrhagic infiltration of the retroperitoneal space to the right and to the left. Phase toxemia. Cut the peritoneum in the upper and lower edge of the pancreas. With the aim of creating a tissue barrier around the affected gland in retroperitoneal fat (along the bottom edge of the head and body of the pancreas) with puncture introduced 100 ml of component No. 1 submitted dissolved in physiological solution of 70 g of dry lyophilized to cryoprecipitate (drug production Altai regional station of blood transfusion). Further, after 10 minutes, the formed infiltration puncture and aspiration introduced component No. 2, consisting of dissolved in 10 ml of 5% ε-aminocaproic acid 150 units NIH sterile thrombin. After 5-7 minutes, was formed artificial fibrin barrier in the retroperitoneal tissue. Complete drainage stuffing bags and abdominal cavity silicone drains. The diagnosis of Aseptic Subtotal CME is p pancreonecrosis, with a primary lesion of the head and body, extensive enzymatic-hemorrhagic infiltration of the retroperitoneal tissue, aseptic enzymatic peritonitis. The postoperative period was uneventful. Received intensive infusion therapy. Quickly recovered intestinal peristalsis, the drains in the first 2 days scant serous-hemorrhagic content. By the end of 2 days of discharge from the drainage has stopped, the drains are removed (8.02.2012 year). Wound healing by primary intention. Infiltration was largely rezorbiruetsa to 7-8 day stay in the clinic. Control MSCT (13.02.2012 g): the pancreas is well visualized, stored slight increase in the area of the head. Its outlines became more clear, the size of infiltration in the retroperitoneal tissue decreased significantly. Remains moderate infiltration in the area of the stuffing bags. For 12 hours after admission (9 days after surgery), the patient was discharged for outpatient follow-up care in a satisfactory condition. Examined as an outpatient after 3 weeks (6.03.2012 g): the condition is quite satisfactory, special dietary needs, prescribed treatment. The abdomen is soft, painless in all departments. Infiltrates in the abdominal cavity is not is palpable pulsation of the abdominal aorta in the epigastric region distinct.

So effective is the efficiency of the proposed method for the treatment of pancreatic necrosis is the use of two-component composition, quickly (within 5-7 min) to form an artificial fibrin barrier distribution enzymatic retroperitoneal phlegmon, without exerting damaging effect on the blood vessels, nerves, with homologically and safety in relation to human tissues.

The method of treatment of pancreatic necrosis by creating in the retroperitoneal tissue restrictive barrier, characterized in that after opening the stuffing bags and abdominal pancreas along the lower edge of its body and tail produce puncture retroperitoneal tissue, which slowly injected component No. 1, consisting of dissolved in 100 ml of physiological solution 50-70 grams of dry lyophilized to cryoprecipitate, then after 10 minutes provide additional puncture retroperitoneal tissue and enter the component number 2, consisting of dissolved in 10 ml of 5% solution of s-aminocaproic acid 150 units NIH sterile thrombin, and after 5-7 minutes due to mixing and polymerization two solutions in the retroperitoneal tissue is formed artificial fibrin barrier preventing the spread of enzyme effusion in the retroperitoneal tissue and the formation of parapancreatic and prikolnoe phlegmon.



 

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3 ex

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1 ex

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1 ex, 1 tbl

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2 ex

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26 cl, 2 tbl, 6 ex

FIELD: medicine.

SUBSTANCE: blood is examined for angiogenic factors, namely soluble fms-like tyrosine kinase (sFlt-1) and placental growth factor (PIGF). An angiogenic factor (Ka) is calculated by formula: Ka=sFlt-1/PlGF×10. If Ka is 10 or less, the pregnant woman is stated to require no admission to hospital, no case follow-up; doctor's appointments are scheduled. If Ka falls within the range of 10 to 50, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed; an amniotic fluid index (AFI) is calculated; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 10 days. The amount of infusion makes 400 ml a day. The prescribed preparations are Actovegin, Trental, Instenon, Carnitini chloridum. Control ultrasonography, Doppler monitoring, foetal monitoring, AFI and Ka measurements are performed 2 weeks later. The pregnant woman is discharged from hospital if observing no negative trends. If Ka falls within the range of 50 to 100, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed, and AFI is measured; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 14 days The amount of infusion makes 800 ml a day. The prescribed preparations are Actovegin, Trental, Instenon, Carnitini chloridum. Control Doppler monitoring and foetal monitoring are performed every 3 days; 2 weeks later control Ka is measured. If the trend is positive, the pregnant woman may be discharged from hospital, while no positive trend requires another 2 weeks of the therapy. If Ka is 100 or more, but less than 150, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed, and AFI is measured; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 14 days. The amount of infusion makes not less than 800 ml a day with the same preparations prescribed. Those are added with the preparations for homeostasis correction, including Fraxiparine, Fragmin, Clexane optionally. Control Doppler monitoring and foetal monitoring are daily. Hypamnion also requires measuring control AFI. If a gestational age is less than 34 weeks, respiratory distress syndrome (RDS) should be prevented by administering the preparation Dexon 24 mg according to the schedule: 6 mg every 12 hours 4 times. Control Ka is necessarily measured after 2 weeks of the treatment. If the trend is positive, the pregnant woman may be discharged from hospital, while no positive trend requires another 2 weeks of the therapy. If Ka is 150 or more, and the gestational age is more than 34 weeks, the therapeutic approach is the same, as for Ka being within 100 to 150, control Doppler monitoring, foetal monitoring are performed twice a day, as well as measuring AFI. If observing no foetal weight gain for 2 weeks of the therapy or the functional state of the foetus deteriorates, a Cesarean section is performed. If the gestational age is 34-36 weeks, the therapeutic approach and follow-up are the same as for the gestational age of 34 weeks, except for the prevention of foetal RDS. However, if observing the deterioration of a foetal movement pattern or the functional status of the foetus, a Cesarean section is performed according to the foetal monitoring and Doppler monitoring findings. If the gestational age is more than 36 weeks, and Ka is 150 or more, pre-mature delivery is applied.

EFFECT: optimal selection of the therapeutic approach ensured by determining the values reflecting the severity of the cardiovascular disorder directly in the uterine-placental complex and mother's and foetus's compensatory capacities.

5 ex

FIELD: medicine.

SUBSTANCE: haemodilution is performed with using crystalloid solutions, nitroglycerin and antihypertensive drugs. The antihypertensive drug is presented by using 5% pentamine intermittently administered after the beginning of the anaesthetic induction; if the effect of pentamine occurred to be inadequate, nitroglycerin is infused in an amount of 10 ml as a 0.1% solution diluted in crystalloid solution 200 ml for maintaining reference arterial blood pressure of 80/50 mm Hg. The nitroglycerin solution is kept to be administered until the wound is sutured, while the additional antihypertensive and blood loss reducing effect is ensured by spinal anaesthesia; as a haemostatic agent, an officinal solution of tranexamic acid 5-10 ml is intraoperatively intravenously introduced under an endoprosthesis bed.

EFFECT: lower risk of postoperative complications and ensured controlled stable arterial blood pressure in the patient.

2 ex

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