RU2141796C1 - Surgical method for treating the cases of chronic pancreatitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying internal anastomosis between pancreas duct and the stomach. Short branches of T-shaped drainage tube are placed into the duct through the duct orifice at the concluding stage. The posterior wall of the stomach is sutured to the pancreas capsule above the exit point of the drainage tube. The long branch of the T-shaped drainage tube is placed along the anterior wall of the stomach. The inferior part of the anterior wall of the stomach is sutured to the pancreas capsule below the exit point of the drainage tube. A canal is built around the long branch of the drainage tube 3-6 cm apart. Gastrostoma is formed. The long branch of the drainage tube is brought through the gastrostoma to the anterior abdominal wall. EFFECT: prevented gastric juice discharge into the pancreas duct. 8 dwg

Description

 The invention relates to medicine and will find application in surgical practice in the treatment of chronic pancreatitis and a number of other diseases of the pancreas.

 Chronic pancreatitis is one of the most common diseases of the gastrointestinal tract (O.B. Milonov, V.I. Sokolov. Chronic pancreatitis. - M .: Medicine, 1976. - 188 p .; M.V. Danilov, V. .D. Fedorov. Pancreatic Surgery: A Guide for Physicians. - M.: Medicine, 1995. - 512 p.). In some cases, a surgical method of treatment is used. Surgery on the pancreas is aimed at performing internal drainage of the pancreatic duct by anastomosing it with the stomach or jejunum (A.A. Shalimov. Diseases of the pancreas and their surgical treatment. - M .: Medicine, 1970, M.V.Danilov, V. D. Fedorov, Pancreatic Surgery: A Guide for Physicians, M: Medicine, 1995. 512 p .; J. Maskie, J. Rhoads: The restoration of pancreatic flow by pancreaticogastrostomy following Whipple resection // Chir.Gastroent . - 1977. - N. 11 - P. 347-349; Surgical Surgery / edited by I. Littmann. - Budapest: Publishing House of the Academy of Sciences GRII - Akademiai Kiado, 1981; B.Niderle et al ,. biliary tract surgery - Prague: Avitsenum Medical Publishing House, 1982).. Such operations are performed with narrowing or complete closure of the mouth of the pancreatic duct, pancreaticolithiasis. Sometimes, internal drainage of the pancreatic duct as a stage of the operation is performed with a tumor of the pancreatic head.

 Studies of patent and medical literature have revealed a number of methods for the surgical treatment of chronic pancreatitis by means of internal drainage of the pancreatic duct.

 So, there is a known method for the surgical treatment of chronic pancreatitis by creating a longitudinal anastomosis between the pancreatic duct and the jejunum (longitudinal pancreatic-jejunostomy), described by various authors (A. A. Shalimov. Pancreatic diseases and their surgical treatment. - M., Medicine, 1970. S. 114-116; Surgical Surgery / edited by I. Littmann, Budapest: Publishing House of the Hungarian Academy of Sciences - Akademiai Kiado, 1981. P. 657-658). It is carried out as follows.

 Perform laparotomy. After dissection of the gastrointestinal ligament, the pancreas is exposed. The pancreas tail is resected. On the surface of the incision of the pancreas, find the opening of its duct. Going from here and dividing the front wall of the gland with scissors, they cut the duct along almost the entire length to the head of the gland. After this, the intestine is prepared for the application of the anastomosis. Form a Y-shaped anastomosis according to Ru. The disconnected loop is led upward behind the transverse colon and placed next to the pancreas. A hole is placed on the anti-mesenteric edge of the intestine, the size of which corresponds to the length of the dissected section of the pancreatic duct. Pancreatic jujunostomy is performed by a two-row suture. The outer row of serous knotted sutures attach the intestine to the capsule of the pancreas. The inner row of very thin knotted sutures mucous membranes of these organs are tightly connected to each other (Fig. 1). A further sequence of overlapping rows of seams is as follows: first, the rear outer, then the rear inner, then the front inner and finally the front outer row of seams.

The disadvantage of this method of treating chronic pancreatitis is the development of postoperative complications due to several factors:
First, in order to find the pancreatic duct, it is necessary to perform a pancreatic tail resection, which increases the invasiveness of the intervention (RL Rossi. Pancreatic resection for chronic pancreatitis // Hepato-gastroenterol. - 1990. - Vol. 37 - N. 6. - P. 277-282).

 Secondly, the imposition of a high-quality anastomosis for a considerable extent is very difficult due to the defeat of the gland by a pathological process (RCWilliamson, MCCooper. Resection in chronic pancreatitis // Brit. J. Surg. - 1987. - Vol. 74. - N. 5. - P. 541-553). This factor can cause anastomosis failure in the postoperative period.

 Thirdly, with this method of applying the anastomosis, intestinal contents enter the pancreatic duct, which causes the development of complications - acute pancreatitis.

 Fourth, during the operation, the loop of the jejunum is carried out through the window in the root of the mesentery of the transverse colon, which can cause damage to the vessels of the root of the mesentery (O. B. Milonov, V. I. Sokolov. - Chronic pancreatitis. - M .: Medicine , 1976.- 188 p.).

 There is a method of surgical treatment of chronic pancreatitis by creating an anastomosis between the pancreatic duct and jejunum of the type "end to side" - term lateral pancreaticojejunostomy (B. Niederle et al. Surgery of the biliary tract. - Prague. Avicenum-Medical Publishing House , 1982). It is carried out as follows. After performing a laparotomy and exposure of the pancreas, the free end of the loop of the intestine is blindly sutured, which is applied sideways to the surface of the resected pancreas. The imposition of a terminal-lateral pancreatic anastomosis begins by sewing the serous membrane of the posterior wall of the intestinal loop to the capsule of the pancreas. After this, an incision is made of the serous-muscular layer of the intestine with a length corresponding to the width of the pancreas, and its edges are sutured to the posterior edge of the incision with thin sutures. In the center, exactly against the pancreatic duct, the exposed mucous membrane is opened in a small incision and the pancreatic duct is sutured to the edges of the mucous membrane with sutures of chromed catgut, applying 5-6 sutures. Finally, the second free edge of sero-muscular incision is sutured to the anterior edge of the pancreas (Fig. 2). In this way, the entire surface of the incision of the pancreas is blocked by the intestinal mucosa and only the duct of the pancreas enters the lumen of the small intestine.

The disadvantage of this method of treating chronic pancreatitis is the development of postoperative complications due to several factors:
Firstly, with this type of anastomosis, the suture is not tight and allows aggressive pancreatic juice or infected intestinal contents to pass through, as some authors indicate (Surgical Surgery / Ed. I. Littmann, Budapest, Publishing House of the Academy of Sciences of Hungary - Akademiai Kiado, 1981, p. 656).

 Secondly, in the area of the anastomosis there is a dead space between the wall of the pancreatic duct and the sutures that connect the intestinal wall with the capsule of the gland. This contributes to the formation of streaks with subsequent possible development of anastomotic insufficiency.

 Thirdly, with this method of applying the anastomosis, intestinal contents enter the pancreatic duct, which causes the development of complications - acute pancreatitis.

 Fourth, during the operation, the loop of the jejunum is carried out through the window in the root of the mesentery of the transverse colon, which can cause damage to the vessels of the root of the mesentery (O. B. Milonov, V. I. Sokolov. Chronic pancreatitis. M., Medicine, 1976 . - 188 p.).

 Fifthly, it is necessary to leave free internal, the so-called "lost" drainage. It is a foreign body inside the pancreatic duct and can cause complications from obstruction of the pancreatic duct to acute pancreatitis (CFFrey. Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum // World J. Surg. - 1990. - V. 14. - P. 59-69).

 There is a method of surgical treatment of chronic pancreatitis by creating an anastomosis between the pancreatic duct and jejunum of the type "end to end", described by several authors (B. Niederle et al., Surgery of the biliary tract, Prague, Avicenum-Medical Publishing House, 1982, p. 286). It is carried out as follows.

 After performing a laparotomy, approach to the pancreas and its resection, the open end of the elongated loop of the jejunum is brought closer to the dissected pancreas. The drainage inserted into the pancreatic duct is advanced approximately 5 cm into the lumen of the intestine and left as free internal drainage. After that, with separate serous-muscular sutures, the circumference of the end of the intestine is circularly sutured to the edges of the incision of the pancreatic capsule and then the pancreas is placed in the lumen of the jejunum. Thus, the wall of the jejunum is wrapped and with its serous surface it is adjacent to the surface of the pancreas. In this position, the wall of the jejunum is again hemmed to the capsule of the pancreas with sutures of the second stage. At the same time pushing the pancreas, tighten the seams. Impose and fix additional seams (Fig. 3).

The disadvantage of this method of treating chronic pancreatitis is the development of postoperative complications due to several factors:
Firstly, you have to leave free internal, the so-called "lost" drainage. It is a foreign body inside the pancreatic duct and can cause complications from blockage of the pancreatic duct to acute pancreatitis (CFFrey. Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum // World J. Surg. - 1990. - V. 14. - P. 59-69).

 Secondly, with this method of applying the anastomosis, intestinal contents enter the pancreatic duct, which is the reason for the development of complications - acute pancreatitis.

 The well-known "Method for the treatment of pancreatic cysts" (E.O. Walter, Copyright certificate N 860752. IPC A 61 B 17/00. B.I. N 33, 1981). It consists in the following: produce a median laparotomy 20-25 cm long, revision of the abdominal organs to determine the relative position of the organs and cysts. Open the gastro-colonic ligament, determine the size of the cyst. They mobilize the greater curvature of the stomach, bandage and cross the left and right gastrointestinal arteries at their junction. A tube is formed from the wall of the stomach along the greater curvature, lined from the inside with a mucous membrane. For this, a flap 5-6 cm long is cut out of its wall according to the large curvature of the stomach, for example, with the NZhKA-60 stapler, and additional serous-muscular sutures are imposed. The diameter of the lumen of the formed tube in the sutured state is 1.5-2 cm; the axis of the cut tube is directed into the cardiac section of the stomach. After puncture emptying of the cyst with the distal end of the formed gastric tube and the wall of the pancreatic cyst, an end-to-side anastomosis is applied, reinforcing it with double-row knotted silk sutures. In the cavity of the cyst for decompression, a nasogastric tube is performed for 3-4 days. The operation is completed by drainage of the abdominal cavity and the stitching of the surgical wound. The tube formed from the wall of the stomach prevents the gastric contents from flowing into the lumen of the cyst and serves as a good drainage for its emptying.

This method, although it eliminates such a significant drawback of creating anastomosis of the pancreas with hollow organs of the abdominal cavity as a reflux of the contents of these organs into the pancreas, has significant disadvantages:
firstly, it involves the creation of an artificial tube from the wall of the stomach. This is preceded by cutting a flap from the wall of the stomach, the imposition of many serous-muscular sutures;
secondly, this operation concerns only the possibility of drainage of the pancreatic cysts, but in no way the pancreatic duct. The pancreatic duct is a finer anatomical structure, which makes it extremely difficult to perform an intervention of this kind on it.

 There is a method of surgical treatment of chronic pancreatitis by creating an anastomosis of the pancreas with a stomach, described by J. Maskie, J. Rhoads (1977) in the article "The restoration of pancreatic flow by pancreaticogastrostomy following Whipple resection" // Chir.Gastroent. - 1977. - N. 11 - P. 347-349. He is selected as a prototype. The technique of the operation is as follows.

 After performing a laparotomy, approach to the pancreas and its resection, the surface of the pancreas incision is stitched with separate sutures so as to preserve the pancreatic duct. Suture threads are left and used later when drawing the pancreas into the stomach. The gland is released at a distance of 3 cm from the surface of the incision. The base of the front surface of the liberated part of the gland is sutured with separate sutures with the posterior wall of the stomach. A transverse gastrotomy is performed with a length of about 3 cm (depending on the width of the pancreas) on the posterior wall of the stomach at least 4 cm proximal to the proposed gastroenteroanastomosis. The threads left on the pancreas are pulled through the gastrotomy opening into the stomach and the needle is passed through its front wall. These threads provide, when applying the anastomosis, the location of the pancreas in the lumen of the stomach. The hemming of the base of the mobilized pancreas to the stomach is completed by suturing between the posterior surface of the pancreas and the posterior wall of the stomach. In the open stomach, a second layer of anastomosis is performed by suturing the pancreas to the gastric mucosa through a suture made of chrome-plated catgut. After crossing the pancreas used to stretch the threads, at least 1.5 cm protrudes into the lumen of the stomach (Fig. 4).

The disadvantage of this method of treating chronic pancreatitis is the development of postoperative complications due to several factors:
Firstly, part of the pancreas is placed inside the stomach, exposing it to direct exposure to the gastric contents.

 Secondly, one of the stages of the operation is performed in the cavity of the open stomach.

 Thirdly, with this method of applying the anastomosis, gastric contents enter the pancreatic duct, which is the reason for the development of complications - acute pancreatitis.

 The aim of the invention is to reduce the number and severity of postoperative complications, reduce the invasiveness of the intervention and prevent gastric contents from entering the pancreatic duct.

 This goal is achieved by the fact that when implementing the method of surgical treatment of chronic pancreatitis, including the creation of an internal anastomosis between the pancreatic duct and the stomach, eliminating the reflux of gastric contents into the pancreatic duct, and the establishment of external drainage for the prevention of anastomotic insolvency, into the pancreatic duct through an opening in short jaws of a T-shaped drainage are placed in it, then a portion of the posterior wall of the stomach is hemmed near the greater curvature to the capsule pancreas above the drainage outlet, then lay a long T-shaped drainage branch along the front wall of the stomach, hem the lower part of the front wall of the stomach to the pancreatic capsule under the drainage outlet and create a channel from the front wall of the stomach around the long drainage branch for 3-6 by stitching the wall of the stomach around the drainage, then through the hole in the wall of the stomach, drain into the stomach and form a gastrostomy at a distance of at least 4-5 cm, through which a long branch of drainage is brought out of the anterior abdominal wall, and then removed through the drain tube gastrostomy not less than 20 days.

 The method is as follows.

 Perform laparotomy. After exposure of the pancreas, its tissue and the anterior wall of the pancreatic duct are dissected for 1-3 cm. Depending on the cause of the intervention, the duct is revised (if necessary, stone removal, bougienage, etc.). Then, short branches of a T-shaped drainage are placed into the duct through the hole and then a portion of the posterior wall of the stomach is hemmed near the greater curvature to the pancreatic capsule above the drainage outlet (Fig. 5).

 Then a long jaw of T-shaped drainage is laid along the anterior wall of the stomach, the lower part of the anterior wall of the stomach is hemmed to the capsule of the pancreas under the outlet of the drainage. In this case, the lower part of the anterior wall of the stomach covers the initial section of the long jaw of the drainage tube like a cuff (Fig. 6).

 Then a channel is created from the anterior wall of the stomach around the long jaw of drainage, stitching the wall of the stomach around the drainage for 3-6 cm with gray-serous or serous-muscular muscular sutures, then drainage into the stomach is carried out through the hole in the wall of the stomach (Fig. 7). The size of the opening in the wall of the stomach should be comparable with the diameter of the drainage tube.

 Proximal, at a distance of at least 4-5 cm, a gastrostomy is formed, through which a long branch of drainage is brought out through the anterior abdominal wall (Fig. 8).

 The drainage tube is removed through the gastrostomy not earlier than 20 days. In this case, a connective tissue channel is formed along the antero-inferior wall of the stomach, connecting the pancreatic duct with the stomach. Due to this localization, reflux of gastric contents into the pancreatic duct is excluded. To close the gastrostomy, additional surgery, as a rule, is not required - it heals independently.

 This method was tested in a clinic for 5 patients.

 Example. Patient K., 45 years old (medical history N 1166/19), was admitted to the Department of Surgery of the Liver and Pancreas of Rostov Medical University. Based on the data of the clinical examination, the diagnosis was established: chronic pancreatitis, pancreaticolithiasis. After preoperative preparation, an operation was performed. In the position of the patient on his back under endotracheal combined anesthesia, a laparotomy was made with a lateral access of 25 cm at the navel. After revision of the abdominal organs, dissection of the gastrointestinal ligament and gastric discharge, the pancreas is exposed upwards: it is densified almost throughout, along its length along the projection of the pancreatic duct, a tuberous cord densified in places is palpated. At the border of the body and tail of the pancreas, its capsule is dissected in the longitudinal direction at a distance of 2 cm.The duct of the pancreas is dissected in the transverse direction, then 12 calculi were extracted from the pancreas by 12 stones from 3 to 6 mm in size. Short branches of a T-shaped drainage tube with a diameter of 6 mm are placed in the pancreatic duct, then a part of the posterior wall of the stomach near the greater curvature is sewn to the pancreatic capsule above the drainage outlet with separate sutures. A long branch of the T-shaped drainage is laid along the front wall of the stomach, the lower part of the front wall of the stomach is sewn to the capsule of the pancreas under the drainage outlet. Around the long branch of drainage for 5 cm, stitching the wall of the stomach around the drainage, a gray-serous channel is formed. Then, through a hole in the wall of the stomach, drainage was carried out into the stomach and a gastrostomy according to Toprover was formed at a distance of 5 cm. Through it, a long branch of drainage is brought out through the anterior abdominal wall. The surgical wound is sutured in layers, leaving drainage to the pancreas.

 The postoperative period was uneventful, without complications. In the postoperative period, the patient received infusion therapy (5 days), antibiotics (9 days), antiferment preparations (5 days). Drainage from the abdominal cavity was removed on the third day due to the lack of discharge. By the fifth day of the postoperative period, after the termination of antiferment therapy with Kontrikal of 100 thousand units / day and Sandostatin 0.2 mg / day, the drainage left in the pancreatic duct and out through the gastrostomy began to release pancreatic juice in an amount from 100 ml / day to 450 ml / day after 2 weeks. Moreover, as a replacement therapy, the patient was prescribed pancreatin and festal. On the 20th day of the postoperative period, the drainage tube from the gastrostomy was removed. By this time, the patient's condition is quite satisfactory. The gastrostomy on its own closed after 5 days. Discharged on the 25th day of the postoperative period in satisfactory condition, no complaints, no dietary restrictions. Examined three months after the operation - no complaints, gained more than 8 kg in weight, does not limit himself in the diet.

 This method of surgical treatment of chronic pancreatitis compared with the known prototype has several advantages.

 Firstly, it is less traumatic, since it does not imply anastomosis and generally sutures on the wall of the pancreatic duct, and, therefore, does not create the prerequisites for their failure subsequently, which helps to reduce the number of postoperative complications.

 Secondly, there is no need during the operation to carry out a loop of the small intestine through the window in the mesentery of the transverse colon, and, therefore, there are no conditions leading to damage to the vessels in the root of the mesentery.

 Thirdly, in the implementation of the proposed method creates a gray-serous channel from the front wall of the stomach, preventing the ingestion of gastric contents into the pancreatic duct, and, therefore, there are no conditions for the development of pancreatitis and pancreatic necrosis caused by reflux of the gastric or intestinal contents.

In addition, the claimed method is preferable to the prototype for the following reasons:
1. Part of the pancreas is not placed inside the stomach (as is done in the implementation of the prototype method), thereby preventing direct exposure of the gastric contents to the wall of the pancreas.

 2. Tissue healing in the postoperative period occurs in the presence of a drainage tube. Thanks to her, in the first or third day after the operation, she prevents compression and overlapping of the created pancreatic-gastric anastomosis with edematous tissues. Subsequently, a gray-serous channel from the anterior wall of the stomach is formed on it, as on a skeleton.

 3. After 20 days, when tissue edema is already absent, and the channel is formed, the tube is easily removed through the gastrostomy, and does not remain inside, as is the case with the methods of "lost" drains.

Claims (1)

 A method of surgical treatment of chronic pancreatitis, involving surgery with an internal anastomosis between the pancreatic duct and the stomach and the establishment of external drainage, characterized in that at the final stage of the surgical procedure, short T-shaped drainage jaws are placed in the pancreatic duct through the opening, then hem part of the posterior wall of the stomach near a large curvature to the capsule of the pancreas above the drainage outlet, then lay the linear branch of the T-shaped drainage along the front wall of the stomach, hem the lower part of the front wall of the stomach to the capsule of the pancreas under the outlet of the drain and create a channel from the front wall of the stomach around the long branch of the drain for 3-6 cm, stitching the wall of the stomach around the drain, through the hole in the wall of the stomach, drain into the stomach and form a gastrostomy at a distance of at least 4 - 5 cm, through which a long branch of drainage is brought out through the front abdominal wall, and the drainage tube is removed through the gast ostomu not less than 20 days.

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