RU2122361C1 - Method of choledocho- and hepaticojejunostomy - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: method includes application of end-to-size anastomosis by two-row suture; immersion of common hepatic or biliary into wall of intestine. In this case, intestine tissues are separated transversely, layer by layer. Circular muscular layer is separated bluntly. The other layers are separated sharply. Submucous layer and mucous membrane are dissected more than distal of wound of seromuscular case. Edge of extrahepatic biliary duct is butt-juxtaposed with submucous base of intestine with microstructure. Then sutured are edges of seromuscular case and wall of extrahepatic biliary duct which is immersed to under distal and side edges of case. EFFECT: possibility of application of anastomosis with antireflux properties, phrophylaxis of reflux-cholangitis, suture deficiency and stenosis of anastomosis.

Description

 The invention relates to medicine, in particular to experimental and clinical surgery, and can be used in the treatment of diseases and traumatic injuries of the extrahepatic bile ducts.

 Choledocho- and hepatikojejunostomy are common methods for restoring the passage of bile into the intestine, which are used for diseases and injuries of the bile ducts. Postoperative mortality is 18-25% (E.I. Halperin, 1991), anastomotic suture insufficiency is observed in 5-15% of cases (Rumi A., Testone G., 1986), stricture recurrence after reconstructive operations in 5.8-35 % of cases (E.I. Halperin et al., 1991). The causes of scarring of biliodigestive anastomoses are - malnutrition and tissue innervation, reflux cholangitis (E. I. Galperin et al., 1982; N.F. Kuzovlev, 1990). Of no small importance in the formation of scar tissue is the nature of the suture material and the technique of the formation of anastomosis (A.G. Zemlyanoy et al., 1994).

 Experimental work and individual clinical observations indicate the promise and effectiveness of using microsurgical techniques for reconstructive and reconstructive operations on extrahepatic bile ducts (B.V. Pozdnyakov, 1983; M.A. Trunin et al., 1989; I.A. Larchenko s et al., 1990; D.Yu. Konovalov, 1993).

 A known method of applying a choledochojejunoanastomosis using elements of a precision operating technique proposed by I. A. Larchenko (ed. St. USSR 4148976 / 28-14, class A 61 B 17/00, "Method for applying a choledochojejunoanastomosis", 11.27.87). The proposed method consists in dissecting the mucous-submucosal-muscular layer of the small intestine along the entire incision line with the formation of a cuff from the serous membrane with preservation of the subserous vasculature with a width of at least double the thickness of the choledoch wall, which covers the joint area of the common bile duct and small intestine, and an anastomosis form with sutures with simultaneous fixation of the cuff to the bile duct wall, while the needle is injected into the bile duct wall at a distance greater than the width of the cuff, the ligature is carried out with the capture of submucosal layers of the bile duct and the small intestine on the serous membrane of the intestine and with the next stroke, the cuff is stitched with the capture of the serous-muscular layer of the common bile duct, after which the knot is tied.

The disadvantages of the method are:
a) the use of the technique of forming an anastomosis "side by side" excludes the possibility of imposing an anastomosis with high structures and damage to the extrahepatic bile ducts;
b) there is no exact comparison of homogeneous tissues of stitched organs, since all layers of the wall except the mucosa are captured in the seam;
c) the method is traumatic, since during the formation of the cuff, the intestinal wall tissue is excised along the entire cut line, which is an additional trauma;
d) with this type of anastomosis, a "blind sac" is formed from the subanastomotic part of the common bile duct, which can be a source of chronic recurrent cholangitis.

 As a prototype, the authors took the method of choledochojejunostomy, proposed by A. N. Velikoretsky (1959), in which, after isolating the common bile duct at a distance of 2-2.5 cm, it is crossed at the site of its entry into the duodenum. The stump of the common bile duct is sewn to the serous membrane of the jejunum with three side seams on each side. Between the posterior wall of the stump of the common bile duct and the anterior wall of the jejunum, 1-2 gray-serous sutures are applied. On the front wall of the jejunum at the site of attachment of the stump of the common bile duct, a longitudinal section is made 1-1.5 cm long and catgut sutures are applied through all layers of the common bile duct and the posterior edge of the small intestine incision. Then, by applying one suture between the anterior wall of the common bile duct and the front edge of the incision in the small intestine, the stump of the common bile duct is completely immersed in the intestinal cavity. On top of the common bile duct, gray-serous sutures are applied to the wall of the small intestine. The bile duct is covered on all sides by the serous membrane of the small intestine.

Disadvantages:
a) there is no exact comparison of homogeneous tissues of stitched organs;
b) the fusion of the common bile duct with the intestinal wall occurs with the formation of granulation tissue, i.e. secondary tension, which can lead to scarring of the anastomosis, reflux cholangitis and obstructive jaundice;
c) this method requires a sufficient length of the bile duct and therefore cannot be used for high strictures and damage to extrahepatic bile ducts;
d) dense connective and scar tissue formed in the region of the anastomosis, as well as longitudinal dissection of the intestine with the intersection of the fibers of the transverse muscles, prevents the mouth of the anastomosis from closing during the passage of the peristaltic wave and does not protect against digestive-biliary reflux;
d) around the mouth of the anastomosis there are no full muscle fibers of the jejunum wall, which excludes the sphincter mechanism.

 Significant differences of the proposed method are that transversely, in layers, separate the intestinal tissue - the circular muscle layer is blunt, the others are sharp, while the submucosal layer and mucous membrane are dissected distal to the wounds of the serous-muscular case, the edge of the extrahepatic bile duct is compared with the submucosal base of the intestine with butt microsalves , then sew the edges of the serous-muscular case and the wall of the extrahepatic bile duct, immersing it under the distal and lateral edges of the case.

 The method developed by the authors is based on the end-to-side choledocho- and hepaticojejunoanastomosis using a microsurgical surgical technique with immersion of the common bile or hepatic duct in the intestinal wall.

 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 or hepatic duct. On the 3rd day after the onset of signs of obstructive jaundice, a laparotomy was made in the right hypochondrium with a Fedorov incision.

 Under an optical magnification of 8-12.5x using microsurgical instruments and a microdermatocoagulator on the mesenteric margin of the jejunum 25 cm from the duodenoenuenal junction, a transverse incision is made by dissecting the serous-muscular case to the submucosa. In this case, the fibers of the circular muscle layer are pushed apart by blunt micro-hooks. Then, under optical magnification, a common bile or hepatic duct is mobilized for 0.5 cm and crossed. In the area of the distal and lateral edges of the incision, the serous-muscular case is stupidly mobilized from the submucosa, with its distal edge turned away. The submucosal layer and mucous membrane are dissected distally to the wounds of the serous-muscular case, respectively, according to the diameter of the anastomosed section of the extrahepatic bile duct. An end-to-side choledocho- or hepaticojejunoanastomosis is formed by applying an internal row of non-penetrating sutures with a 8/0 thread between the edges of the wounds of the extrahepatic bile duct and the submucosal base of the jejunum, butt to butt, tying the nodules towards the muscle layer of the latter. The outer row of microsutures is applied between the wall of the extrahepatic bile duct and the wound edge of the serous-muscular case, immersing the duct under its distal and lateral edges.

 The method was carried out in an experiment in 20 outbred dogs weighing 8-20 kg, which previously created mechanical jaundice by ligation of the common bile or hepatic duct. 3 days after this, a relaparotomy was performed and chledocho- or hepaticojejunoanastomosis was applied according to the procedure described above.

 In the postoperative period, clinical signs of obstructive jaundice passed within 4-6 days: feces and urine acquired normal color, blood bilirubin level 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, the contrast enters the jejunum freely. When conducting a test for enterobiliary reflux (with a pressure in the intestinal lumen of 120-150 mm Hg), a water-soluble contrast medium does not enter the bile ducts. The pressure in the jejunum is normally 40-60 mm of water. Art. On the section, when opening the jejunum, the anastomosis looks like a pinhole in the transverse fold of the intestinal mucosa. When sounding through an anastomosis, a probe 3-4 mm in diameter passes freely. In a histological examination, epithelialization of anastomoses occurs no later than 5 days, healing to the entire depth of the wall - within 15-17 days.

 Examples of specific performance.

 1. Protocol 35. Outbred dog weighing 16 kg. Under intravenous anesthesia, an upper median laparotomy was performed. The diameter of the common bile duct is 2.5 mm. The choledoch is bandaged in the supraduodenal section. The wound of the abdominal wall is sutured tightly. After 72 hours, a dark color of urine, white feces, and blood bilirubin of 72 μm / l are noted. Under intravenous anesthesia, a laparotomy was performed in the right hypochondrium according to Fedorov. Under an optical magnification of 12.5x, with the help of microsurgical instruments, the common bile duct was crossed above the ligature, mobilized over 0.5 cm. A common bile duct was 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 7.5 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 test for enterobiliary reflux was performed at an intestinal pressure of 150 mm of water. Art. there is no reflux of a contrast agent into the bile ducts. 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. During histological examination, the tissues of the walls of the common bile duct uniformly pass into histologically homogeneous tissues of the submucosal layer and mucous membrane of the jejunum. Muscle tissue covers the common bile duct from all sides and is fused with it through a thin connective tissue layer. Liver tissue maintains its normal structure.

 2. Protocol 49. Outbred dog weighing 13 kg. On the 3rd day after the creation of 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 slightly enlarged, compacted. Formed hepatikoyunoanastomosis according to the described method. The laparotomy wound is sutured tightly. The postoperative period was uneventful. The disappearance of clinical signs of obstructive jaundice was noted by the 5th day. On day 14, the animal was withdrawn from experience. On the section in the area of the anastomosis are several thin loose adhesions. Bile in the ducts of normal color, without pathological signs. A histological examination determines the epithelization in the region of the anastomosis, the mucosa of the common hepatic duct evenly 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.

 In all cases, there were no complications: failure of sutures, stenosis of the anastomosis, cholangitis. The healing period of the anastomosis occurs earlier than with conventional methods, and is 15-17 days.

 In clinical practice, the method was used in reconstructive operations on extrahepatic bile ducts in 12 patients due to: stricture of hepatic choledocho after intraoperative and household trauma of the bile ducts - in 5, intraoperative damage to the bile ducts - in 1, cystic lesions of the common bile duct - in 2, inductive pancreatitis with compression of the retroduodenal part of the common bile duct - in 2 and pancreatic head cancer (with pancreatoduodenal resection) - in 2 patients.

 We present clinical examples of the use of the method.

 Example 1. Patient P., 9 years old, in October 1994, external drainage of a cyst of the common bile duct was performed. During the audit it was found that the common hepatic duct 1.2 cm long flows into the cyst, measuring 15.0 x 7.0 x 7.0 cm, strained, containing infected bile and small calculi, extending to the retroduodenal biliary tract. Clinical manifestations were: jaundice, pain in the right hypochondrium, high body temperature, chills. After normalization of body temperature and liver functions, 1.5 months after a choledochostomy, reconstructive surgery was performed. Under endotracheal anesthesia, a laparotomy was performed in the right hypochondrium according to Fedorov. The common bile duct, its entire supraduodenal part to the common hepatic duct, is represented by sharply thickened sclerotic cyst walls up to 0.5 cm, the dimensions of which were reduced to 3.5 x 2.5 cm, the inner surface is covered with fibrinous plaque. On the operating cholangiogram, patency of the distal segment of the common bile duct was absent, the common hepatic and lobar ducts were not dilated. An excision was made of a cystically altered common bile duct, the walls of which were sclerotic in this area, and the epithelium was absent.

 Hepaticojejunoanastomosis was imposed according to the described method using microsurgical surgical technique under a 6-fold increase in a binocular operating magnifier with a 6/0 monofilament prolene suture. Replaceable hepatic drainage was not used. The early postoperative period was uneventful. Inspected 02/20/96, no complaints, laboratory tests within normal limits.

 Example 2. Patient G., 59 years old, on March 23, 1995, in a district hospital during cholecystectomy for cholelithiasis, choledocholithiasis, the common bile and hepatic ducts were accidentally excised. External drainage of the lobar ducts with two vinyl chloride tubes was performed. The postoperative period was complicated by purulent cholangitis, cholangiogenic sepsis, the formation of multiple liver abscesses due to cicatricial narrowing of the mouth of the right hepatic duct, due to displacement of the drainage tube from it. On June 5, 1995, a relaparotomy was performed, the ends of the lobar hepatic ducts were isolated over 0.5 cm, hepatikojejunanastomoses with jejunum were separately formed according to the described technique with a precision suture 7/0 monofilament suture thread using microsurgical technique without frame drainage. The early postoperative period was uneventful. Inspected March 15, 1996, i.e. 1 year after surgery. No complaints, no signs of regurgitation cholangitis, laboratory tests are within normal limits.

 All operated patients had no complications in the form of insufficiency of sutures, anastomosis stenosis, reflux cholangitis, which indicates the reliability of the proposed method and high antireflux properties.

Claims (1)

 The end-to-side choledocho- and hepaticojejunojunostomy by a double-row suture by immersion of the common bile or hepatic duct in the intestinal wall, characterized in that the intestinal tissue is transversely, layerwise separated - the circular muscle layer is blunt, the rest is acute, while the submucous layer and the mucous membrane are dissected distal wounds of the serous-muscular case, compare the edge of the extrahepatic bile duct with the submucosa of the main intestine end-to-end with a microseam, then the edges of the serous-muscular case and the wall of the extrahepatic bile proto-stitch and, immersing him in the distal and lateral edges of the case.