RU2122360C1 - Method of choledochojejunostomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method includes formation of tunnel of intestine wall, conduction of common biliary duct into tunnel to under seromuscular case of jejunum intestine through two transverse parallel incisions; dissection of submucous layer and mucous membrane in region of distal incision. Incision corresponds to diameter of common biliary duct; formation of anastomosis of butt-suturing the edges of connective layer of wall of common biliary duct with edges of submucous base. EFFECT: improved antireflux properties of biliodigestive anastomosis, reduced terms of its healing and higher reliability of anastomosis.

Description

 The invention relates to medicine, in particular to experimental and clinical surgery, and can be used in the treatment of diseases of the hepatobiliary system.

 Choledochoejunostomy is one of the common methods of internal drainage used for diseases of the hepatobiliary system, including iatrogenic injuries of the extrahepatic bile ducts.

 According to E.I. Halperin et al. (1991) mortality after reconstructive operations on the extrahepatic bile ducts due to their intraoperative injuries and cicatricial strictures reaches 18 - 25%, relapse of stricture of biliobiliary and biliodigestive anastomosis occurs in 5.8 - 35% of cases, and 9.2% of patients after corrective operations become disabled due to biliary cirrhosis of the liver, portal hypertension arising against the background of a chronic inflammatory process in the bile ducts caused by reflux cholangitis [3, 5, 7].

 A method for the prevention of reflux cholangitis and related complications is the creation of biliodigestive anastomoses with areflux and antireflux properties.

 A known method of choledochoenterostomy proposed by V.S. Gudimov and A.N. Nekhaev [1], which consists in creating a subserous canal on the posterior wall of the intestine, conducting a cholechod through it, which is then sutured to the mucous-submucous membrane with the formation of a stub by suturing the edge of the incision of the anterior intestinal wall to the posterior proximal anastomosis.

The disadvantages of the method are:
1. Lack of a full-fledged muscle layer of the small intestine above the cholechoid, necessary to create the sphincter mechanism of biliodigestive anastomosis.

 2. The healing of the anastomosis occurs by secondary intention due to the impossibility of an exact comparison of homogeneous tissues of the stitched organs.

 3. When hemming the edges of the incision of the anterior intestinal wall to the back, the suture line is rough, exposed to bile, which contributes to the occurrence of anastomositis, deformation of the anastomosis, digestive-biliary reflux, cholangitis, the development of ligature lithiasis.

 4. Perhaps the development of insufficiency of the seams of the formed stub.

 A known method of choledochoduodenostomy using a microsurgical technique proposed by D.Yu. Konovalov [2], which consists in cross-section of the bile duct and duodenal wall and the formation of an anastomosis “side to side” between them with a two-row microsurgical suture without trapping mucous membranes, stitching the edges of the sutures with the inner row of sutures wounds of the cholechoid and submucosal layer of the intestine, external - sew the wall of the common bile duct with serous and muscle layers of the intestine.

 The implementation of this method presents great technical difficulties in the cicatricial-adhesive process around the duodenum, especially difficult to perform with high strictures and damage to the extrahepatic bile ducts.

 As a prototype, the authors took the tunneling method of areflux anastomosis, developed in an experiment by E.P. Tsvetov (cited by E.I. Galperin) [3], in which the serous and muscle layers of the duodenum wall are cut in two parallel-transverse sections, in the submucosa a layer forms a tunnel into which the distal end of the dissected duct is pulled, after which the intestinal lumen is opened and two ends of the catgut thread are fixed with curved needles, which fix the edges of the duct, which are then removed through a wall puncture to the outwards are 3-4 cm from the edge of the incision. When tying the ends of the thread, the bile duct is drawn into the lumen of the intestine, after which it is fixed to the mucous membrane.

Disadvantages:
1. During repeated operations, the duodenum is involved in the adhesion process, periduodenitis occurs, its motility is impaired, which can cause reflux cholangitis [6].

 2. In most cases, due to the scar-adhesion process around the duodenum, the creation of choledochoduodenal anastomosis presents great technical difficulties [7].

 3. The duct section protruding into the lumen of the intestine is subsequently necrolyzed.

 4. There is a possibility of atrophy and cicatricial degeneration of the muscle layer of the intestine over the duct due to the greater invasiveness of manipulations when using general surgical technique.

 The method developed by the authors is based on the end-to-side choledochojejunoanastomosis technique using microsurgical surgical technique. The use of the jejunum for the formation of biliodigestive anastomosis without tension is possible with any department of extrahepatic and intrahepatic bile ducts.

 The novelty and significant differences are that the common bile duct is carried out in the tunnel under the serous-muscular case of the jejunum through two transverse parallel sections, the submucosal layer and the mucous membrane are cut in the region of the distal section according to the diameter of the common bile duct, and anastomosis is formed by suturing the edges of the connective tissue layer of the common bile duct wall with the edges of the submucosa of the intestine joint to joint.

 The method proposed by the authors allows to strengthen the antireflux and areflux properties of a biliodigestive anastomosis, reduce the healing time and increase the reliability of the anastomosis.

 The method is as follows. Outbred dogs of various sexes and weights under thiopental anesthesia created a model of obstructive jaundice by ligation of the common bile duct in the supraduodenal section. On the 3rd day, after the appearance of signs of obstructive jaundice, a laparotomy was made in the right hypochondrium with a Fedorov incision.

 Under an optical magnification of 8-15x using microsurgical instruments, a microdermatocoagulator on the mesenteric margin of the jejunum 25 cm from the duodenojejunal junction, two parallel transverse incisions are made at a distance of 10 mm from each other by dissection of the serous-muscular layer to the submucosa. The proximal incision in size corresponds to the outer diameter of the common bile duct, the distal incision is 2–2.5 times larger. In this case, the serous and longitudinal muscle layers are dissected, the fibers of the circular muscle layer are pushed apart with blunt micro-hooks. After that, under optical magnification, the common bile duct is mobilized for 1 cm and crossed in the supraduodenal section.

 Between parallel sections, a tunnel is stupidly made under the serous-muscular case, through which the common bile duct is pulled using 2 strands of holders. In the area of the distal section, the intestinal lumen is opened by dissection of the submucosal layer and the mucous membrane in the transverse direction by the length of the bile duct diameter. An end-to-side anastomosis is formed by suturing the walls of the common bile duct and the submucosa of the intestine without trapping the mucous membranes, tying nodules from the outside. The serous-muscular case over the anastomosis is sutured with separate nodal or continuous suture. An inter-intestinal anastomosis is superimposed between the leading and outlet sections of the intestinal loop.

 The method was carried out in an experiment in 20 outbred dogs weighing 8 to 20 kg, which previously created mechanical jaundice by ligation of the common bile duct. 2–3 days later, a relaparotomy was performed and choledochojejunoanastomosis was applied according to the method described above.

 In the postoperative period, clinical signs of obstructive jaundice passed within 4 to 7 days: feces and urine acquired normal color, the level of blood bilirubin decreased to normal. In no case was failure of anastomotic sutures observed.

 In the long term, up to 6 months, the animals are clinically healthy. With cholangiomanometry, pressure is within the physiological norm. On cholangiograms, the intrahepatic bile ducts are not dilated, in the anastomosis, the common bile duct looks like a “writing pen”, the contrast medium passes freely into the jejunum. When conducting a test for enterobiliary reflux (with a pressure in the lumen of the intestine 90 - 300 cm of water. Art.) - water-soluble contrast medium does not enter the bile ducts. On the section, when opening the jejunum, the anastomosis looks like a pinhole in the transverse fold of the intestinal mucosa. When probing, an probe with a diameter of 3-5 mm passes freely through the anastomosis. In a histological examination, epithelialization of anastomoses occurs no later than 5 days, healing to the entire depth of the wall within 15 to 20 days. The sero-muscular case over the common bile duct in the tunnel is preserved.

 Examples of specific applications.

 1. Protocol N 30. Outbred dog weighing 20 kg. Under intravenous anesthesia, an upper median laparotomy was performed. The diameter of the common bile duct is 3 mm; the common bile duct is ligated in the supraduodenal region. The wound of the abdominal wall is sutured tightly. After 48 hours, a dark color of urine, white feces, is noted. Blood bilirubin - 48 μm / l. Under intravenous anesthesia, a laparotomy was performed in the right hypochondrium. During the audit, the expanded extrahepatic bile ducts, the enlarged, strained gallbladder are determined. The diameter of the common bile duct is 6 mm. Under an optical magnification of 12x, with the help of microsurgical instruments, the common bile duct is crossed above the ligature, mobilized for 1 cm. The common bile duct is formed according to the method described above. The wound of the anterior abdominal wall is sutured in layers tightly. In the postoperative period, on the 5th day, urine and feces acquired their usual color. Blood bilirubin 8 μm / L. After 6 months, the animal is clinically healthy. With cholangiomanometry, the pressure is within the physiological norm. On the cholangiogram, the intrahepatic bile ducts are not dilated, the contrast penetrates the jejunum freely.

 A digestion digestive reflux test was performed at an intestinal pressure of 200 cm water column. - reflux of a contrast agent into the bile ducts was not noted. On the section, the anastomosis is located in the transverse fold of the mucous membrane in the form of a closed slit 3 mm long. A probe with a diameter of 4 mm passes unhindered through the anastomosis. The sero-muscular case over the intraparietal site of the common bile duct does not externally differ from other parts of the intestinal wall; upon palpation, it is soft, without compaction. During histological examination of the tissue, the walls of the common bile duct uniformly pass into histologically homogeneous tissues of the submucous and mucous layers of the jejunum. The muscle and serous layers of the jejunum are fused together without the development of scar tissue. The muscle layer above the common bile duct is preserved without signs of degeneration. Liver tissue maintains its normal structure.

 2. Protocol N 46. Outbred dog weighing 11 kg. 3 days after creating a model of obstructive jaundice, a laparotomy was performed in the right hypochondrium. The enlarged extrahepatic bile ducts are determined, the gall bladder is stretched, the liver is enlarged, somewhat densified. Formed choledochojejunanastomosis according to the described method. The laparotomy wound is sutured tightly. The postoperative period is smooth. The disappearance of clinical signs of obstructive jaundice was noted by the 5th day. On day 20, the animal was withdrawn from experience. An insignificant number of fine adhesions in the anastomotic region were found in the section. The sero-muscular case over the intraparietal section of the common bile duct does not differ from neighboring sections of the intestine. Bile in the ducts of normal color, without pathological impurities. Histological examination determines the epithelization of the anastomotic region, the mucosa of the common bile duct passes into the mucosa of the small intestine, the connective tissue layer of the duct wall passes into the submucous layer of the intestine, and there is no scar tissue in the region of the anastomosis.

 The method allows under conditions of obstructive jaundice and inflammatory changes to create choledochojejunoanastomosis, characterized by high functional properties, in particular high antireflux properties and reliability.

 In all cases, there were no such complications as insufficiency of sutures, anastomosis stenosis, cholangitis. The healing period of the anastomosis occurs earlier than with conventional methods and is 20 days.

Literature
1. Copyright certificate of the USSR 1449117, cl. A 61 B 17/00. The method of choledochoenterostomy (B.S. Gudimov, A.N. Nekhaev), N 3779842 / 28-14, decl. 08/13/84. Publ. Bull. N 1 // Discoveries. Inventions 1989, N 1, p. 20.

 2. D.Yu. Konovalov. Patent N 2008815, CL A 61 B 17/00.

 3. Halperin E.I., Kuzovlev N.F., Karagyulyan S.R. Cicatricial strictures of the bile ducts. - M.: Medicine, 1982, 240 p.

 4. Halperin E.I., Dederer Yu.M. Non-standard situations during operations on the liver and biliary tract. - M.: Medicine, 1987, 336 p.

 5. Halperin E.I., Volkova N.V. Diseases of the biliary tract after cholecystectomy. - M.: Medicine, 1988, 272 p.

 6. Zemlyanoy A.G., Glushkov N.I., Janet A.K. Surgical tactics for cicatricial strictures of the bile ducts. Maykop, 1994.

 7. Krakowski A.I., Ivannikov N.F., Makovskaya T.P. et al. Essays on the pathology and surgery of obstructive bile duct. - Tomsk, 1982, 305 s.

Claims (1)

 The method of choledochoejunostomy by forming a tunnel in the intestinal wall, characterized in that the common bile duct is led into the tunnel under the serous-muscular case of the jejunum through two transverse parallel sections, the submucosal layer and the mucous membrane are cut in the distal section according to the diameter of the common bile duct, and an anastomosis is formed by stitching the edges of the connective tissue layer of the wall of the common bile duct with the edges of the submucosa of the intestine "butt to butt".