Hepatic Vascular Fully Implantable Drug Pump Implantation

The drug delivery system (DDS) was originally used in the early 1970s and has been widely used in the treatment of advanced tumors, and has achieved good results. At the same time, DDS can also provide infusion routes for long-term infusion and drug treatment, as well as long-term analgesic treatment for advanced tumors. DDS is mainly composed of the following parts. 1. The pouch is a 3cm in diameter and has a clamshell shape. The top is a special layer of membrane. It is a puncture injection site. The periphery is made of plastic or metal. The bottom has a metal piece to prevent the needle from penetrating. The capsule cavity is about 0.4 to 1.6 cm and communicates with the catheter. The diaphragm can withstand thousands of punctures without breaking, preventing leakage. There are many types of DDS, which can be divided into arterial, venous and abdominal according to different catheter implantation methods. According to the presence or absence of anti-reflux device, it can be divided into common type and anti-reflux type; according to the presence or absence of power device, it can be divided into Power pump type and non-power pump type; according to the number of capsules and catheter lumens can be divided into single-capsule single-chamber type, single-capsule double-chamber type, double-capsule single-chamber type and double-capsule double-chamber type. The advantages of DDS are: 1 wide application, suitable for various routes of medicine; 2 safe and reliable; 3 accurate guidance, to achieve the purpose of local treatment; 4 easy to operate, can be used repeatedly; 5 less complications, can reduce the toxicity of chemotherapy The reaction improves the therapeutic effect. DDS is mainly used for chemotherapy of advanced liver cancer. The implantation route is hepatic artery, portal vein and hepatic artery-portal vein. Hepatic artery catheterization pathways include left hepatic artery, right gastro-intestinal artery, gastroduodenal artery, right gastric artery and gastric retinal artery. Generally, DDS is implanted in the middle or advanced stage of liver cancer with right hepatic artery or left hepatic artery ligation. Portal vein implantation methods include umbilical vein, right gastric vein, colonic vein, and superior mesenteric vein. 2. The catheter (gatheter) is made of silica gel and is 60-76 cm long. The artery-shaped tube wall has an anti-slip knot to prevent it from falling off. Some catheters have a check valve at the end to prevent blood from flowing back. The connector connects the sachet to the catheter. 3. Noncoring needle The tip of the needle is slightly curved, and the tip of the needle is triangular in shape, so that it penetrates into the septum of the capsule and forms a diagonal tunnel without tearing. Treatment of diseases: liver cancer liver cirrhosis Indication 1. Unresectable primary or metastatic liver cancer, DDS implantation at the same time as hepatic artery ligation. 2. Postoperative chemotherapy after palliative resection of liver cancer. 3. No severe cirrhosis, normal liver function, no ascites, jaundice, no serious lesions in the heart, lungs, kidneys and other organs. Contraindications 1. Severe cirrhosis, portal hypertension, postoperative recovery difficulties, although palliative resection of liver cancer, DDS implantation is not appropriate. 2. The primary metastatic liver cancer was not removed. 3. In the advanced stage of liver cancer, the main portal vein tumor thrombus and lymph node metastasis have been unable to tolerate chemotherapy. 4. Hepatic artery variation is difficult to separate. 5. With serious heart, lung, kidney and other diseases. 6. Patients with coagulopathy. Preoperative preparation 1. Liver treatment 1 If the patient is malnourished, it should be given a high protein, high sugar and high vitamin diet. It is best to give a daily diet containing 10.46 ~ 14.64kJ (2500 ~ 3500cal) calories, especially for liver malignant tumors, It is especially important to have cirrhosis or eat less. For those without diabetes, a certain amount of glucose can be given orally or intravenously daily. Oral or intramuscular injection of vitamins B, C, K. In patients with prolonged prothrombin time or bleeding tendency, large doses of vitamin K should be given to improve coagulation. 2 for patients with low plasma protein, should be supplemented with appropriate amount of plasma or albumin, if necessary, a small number of multiple blood transfusions, to achieve serum total protein of more than 60g / L, albumin up to 30g / L. 2. If liver cancer resection is performed at the same time, preoperative preparation for liver resection is also needed. 3. Blood should be matched before surgery, fasting in the morning and leaving the stomach tube. 4. Select different types of DDS according to different conditions, and sometimes prepare several kinds of DDS for intraoperative selection. Surgical procedure 1. Gastric duodenal artery DDS implantation (1) Separation of blood vessels: The duodenal ligament is exposed after the abdomen, and the left hand of the surgeon extends into the small omentum hole, and the position of the hepatic artery, the common hepatic artery and the gastroduodenal artery is touched with the thumb. . The hepatic artery is isolated and threaded through the proper hepatic artery and lifted. The common hepatic artery and the gastroduodenal artery were separated down the hepatic artery, and the gastroduodenal artery was separated from the upper edge of the duodenal bulb by about 1 to 2 cm. The distal end was double-ligated with a silk thread. The end sleeve is made of silk. The left and right arteries of the liver are separated upward from the proper hepatic artery, and the right gastric artery is ligated and cut. (2) Preparation of DDS: If the sachet and the catheter are detachable, connect the catheter to the sachet and fix it. Add 100 mg of heparin to 100 ml of normal saline to prepare heparin solution, take 3 to 5 ml of heparin solution with an empty needle, replace it with a non-invasive needle, puncture it into the sachet, and inject it, so that the gas in the sachet and the catheter is discharged and filled with heparin solution. . The catheter has a length of 15 to 20 cm and the end is cut into a slope. (3) Place the catheter: the assistant lifts the proximal sheath of the gastroduodenal artery to block the blood, and pulls the distal ligature in the opposite direction to maintain the tension of the artery; the surgeon cuts the gastroduodenal artery into a small mouth. The left hand uses the plastic fistula to lift the anterior wall of the arterial incision, and the right hand uses the forceps to clamp the end of the catheter into the artery. The assistant gently relaxes the sheath to allow the catheter to enter the proper hepatic artery. The catheter walks to the left and right hepatic bifurcation. If it is necessary to insert the right hepatic artery, the left hepatic artery is sheathed, and the catheter is transferred to the right hepatic artery 2 to 3 cm. The gastroduodenal artery is double-ligated with a thin wire. The end is fixed to the non-slip knot. The capsule was intrapulally injected with 1 to 2 ml of methylene blue, and the liver staining was observed to determine the position of the catheter, and then 3 ml of heparin solution was injected. (4) Chemotherapy and embolization injection: If only chemotherapy drugs are injected, it is only necessary to push each drug through the drug capsule in turn. If the embolization dose is injected, the catheter and the drug capsule should be disassembled, and the chemotherapeutic drug and the iodized oil should be mixed into an emulsion and then injected through the catheter. The gelatin sponge is cut into pieces and mixed with physiological saline, and then injected through the catheter. Connect the catheter to the sachet and inject heparin. (5) burial of the drug capsule: if the incision is under the right costal margin, the medicinal sac can be buried under the incision under the incision, and the obese patient can also be buried under the incision. The rectus abdominis incision is buried 3.0cm above the umbilicus on both sides of the incision, and the wasting patient can also be buried under the anterior sheath of the rectus abdominis. A 5 cm wide and 3 cm tunnel was separated between the subcutaneous fat and the abdominal muscle fascia and the bleeding was completely stopped. Then, the sachet was placed in the tunnel and fixed, the tunnel opening was closed, and the abdominal cavity was closed layer by layer. 2. Umbilical vein DDS implantation After the abdomen, the liver round ligament is cut, the liver is ligated, the umbilical vein is found at the proximal liver, the vein wall is clamped with a mosquito clamp, and the vein is inserted into the vein for expansion, and the umbilical vein is opened with a little force. The diaphragm between the portal veins is pulled out of the probe and the catheter is inserted into the umbilical vein after the blood has flowed out. When the catheter was inserted 10 cm, the surgeon touched the portal vein to prevent the catheter from being transferred to the trunk through the left portal vein. After adjusting the catheter position, the umbilical vein fixation catheter was ligated. The liver and duodenal ligament were temporarily blocked, and the liver staining was observed by intraductal injection of methylene blue to determine the catheter site. Drug injection and sachet burying the same gastric and duodenal artery DDS. In addition to the umbilical vein, the catheter can be placed through the middle venous vein and the middle venous venous vein. This path is more suitable for patients with umbilical vein failure. In recent years, the femoral artery or the supraclavicular artery has been directly intubated to the hepatic artery, and the sachet is fixed to the inner side of the thigh or the subthoracic wall. complication 1. catheter shedding and bleeding The reason is that the catheter is not firmly fixed, especially when the arterial pressure is high, the catheter is easily detached, resulting in massive bleeding in the abdominal cavity. In addition, the catheter is not firmly connected to the sachet, and the intra-abdominal catheter remains too short to be pulled away. Therefore, the ligation should be strong when the catheter is fixed, and must be double-ligated. The arterial catheter ligature must be fixed on the non-slip knot. The catheter should be tightly connected to the sachet, and if necessary, bundled with a silk thread. The catheter should not be too short and there should be no tension. 2. Pouch and subcutaneous infection Mainly due to the sanitation of the skin is not strict, the operation does not pay attention to aseptic technique or the needle is not disinfected, so that bacteria are brought into the sachet or subcutaneous tissue. If the infection in the sac is found, the blood in the sac is taken out for bacterial culture, and the antibiotic and the whole body intravenous antibiotic are injected into the sac. After the infection is controlled, the symptoms disappear, and the antibiotic is continued for 2 to 3 days, 2 weeks later. Then enter anticoagulation, if there is no more fever, DDS can still continue to use. If the infection cannot be controlled after treatment, the DDS is no longer usable and must be removed. Subcutaneous infection, in addition to systemic application of antibiotics, local hot compress, physical therapy, promote inflammation absorption; if the infection has subsided, the drug capsule is smooth, you can continue to use; if the drug capsule is not smooth, infection is not easy to control, the capsule should be taken out. 3. Pouch and catheter blockage The main reason is that the anticoagulation is not on time. If the knot is tightened and the lumen is narrowed when the catheter is fixed, it is easier to block the catheter. In general, an arterial catheter is required to be anticoagulated once every 2 weeks, and the intravenous catheter is administered once every 3 weeks. If the resistance is felt when the anticoagulant is injected within the above time, the anticoagulation cycle can be shortened. It is found that catheter obstruction can be firstly tried with TB empty needle to extract heparin solution. Some patients can clear the catheter. If it still cannot be dredged, urokinase or streptokinase solution can be injected into the drug capsule to dissolve the thrombus, and anticoagulation is performed on the second day. Most of the catheters can be dredged. 4. The rupture of the sac and the extravasation of the liquid Mostly caused by rupture of the capsule. The cause of the diaphragm rupture is related to the quality, but also related to the wear of the puncture needle and the improper puncture method. Therefore, it is found that the needle becomes dull and the needle tip cannot be used if it is rolled. The extravasation of the drug solution is characterized by swelling of the subcutaneous tissue around the drug capsule, and there is a fluctuating infection. When the drug is irritating, it may cause pain or even skin necrosis. The drug capsule should be taken out. 5. Upper abdominal pain, nausea and vomiting Most occur after anticoagulation or chemotherapy. The incidence of arterial catheters is high, while venous catheters are rare. The reason is the gastrointestinal reaction caused by chemotherapy drugs; the right gastric artery is not ligated, so that the chemotherapeutic drug reverses into the right gastric artery and causes chemotherapy drug gastritis; after the hepatic artery is repeatedly stimulated by the drug, the intimal hyperplasia, the lumen narrows, and the resistance increases. Anticoagulation or chemotherapy causes severe pain in the liver area, which occurs more than half a year after DDS implantation. Gastric mucosal drugs can be orally administered during chemotherapy, and lidocaine or procaine can be injected before each anticoagulation or chemotherapy to reduce vascular irritation. If the abdominal pain is severe and unbearable, the chemotherapy should be suspended, or the micro-electron pump should be used for continuous infusion, and symptoms such as abdominal pain and vomiting will be significantly alleviated.