RU2158546C2 - Method for making pancreatogastroduodenectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves removing the mobilized pancreatogastroduodenal complex and creating pancreatojejunal end-to-end anastomosis with pancreas stump invaginated into jejunum lumen on carcass-type draining tube. Drainage is carried out through single-row intestine stump suture into its lumen. The draining tube is brought outside through the nose. Gastrojejunal end-to- side anastomosis is carried out on the resection line near the lesser curvature of the stomach. Choledochojejunal anastomosis is applied with choledochus stump invaginated into the intestine lumen using double-row seroserous sutures without suturing mucous membranes together. The choledochus is drained with carcass-type draining tube. The tube is brought through a cut in intestine wall towards the abdominal wall. EFFECT: low risk of pancreatojejunal anastomosis inconsistency and reflux-cholangitis occurrence and forming strictures.

Description

 The invention relates to medicine, specifically to surgery, and relates to methods of pancreato-gastroduodenal resection.

 Known methods of pancreato-gastroduodenal resection by resection of a part of the stomach, duodenum, pancreas head and application of pancreatojejunoanastomosis, gastrojejunoanastomosis, choledochojejunoastomosis [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11].

 However, these methods have several disadvantages. Pancreatojejunostomy is applied according to the type of “side to side”, “end to end”, “end to side”, more often with the formation of an anastomosis between the main pancreatic (Wirsung) duct and intestine, using even precision technology, which is associated with the risk of failure of anastomotic sutures due to the fragility of the thin duct wall, or the formation of the structure due to imperfection of the suture material. If it is impossible to apply an anastomosis between the duct and the intestine, the duct is ligated or filled, which can lead to the development of pancreatic necrosis. Gastroejunoanastomosis is also applied according to various methods: end-to-end, end-to-side, anterior, posterior, but more often according to the Hoffmeister-Finsterrer method, which with term-terminal pancreatojejunoanastomosis can lead to the throwing of gastric contents into the pancreatic ducts and the development of pancreatic necrosis . In other types of anastomosis, there is a large percentage of post gastroresection disorders. The techniques for applying choledochojejunoanastomoses also involve stitching the duct wall, often thin and tender, which leads to failure of the anastomotic sutures. The imposition of conventional leads to the formation of the structure of the anastomosis, the development of reflux cholangitis. The generally accepted sequence of pancreatojejunoanastomosis, biliodigestive anastomosis, gastrosunoanastomosis, the use of an isolated loop create conditions for intestinal stasis and a violation of the natural passage of the chyme.

 The closest (prototype) is a method consisting in conducting an operational audit, mobilizing the pancreatoduodenal complex, removing the drug and conducting the reconstructive phase of the operation. The stump of the initial section of the jejunum is sutured with the UO apparatus, in the center of the mechanical suture a small area is cut out for the anastomosis with the pancreatic duct. The back row of nodal sutures, capturing the serous-muscular layer of the intestine and the posterior surface of the pancreatic stump, is laid in such a way that the stump of the gland is immersed in the intestinal lumen. The mucous membranes of the intestine and pancreatic duct are compared with the next row of sutures; finally, the formation of an invagination pancreatojejunoanastomosis is completed by the front row of gray-serous sutures. The second stage impose choledochojejunanastomosis. In this case, the stump of the common gastric duct is laid across the intestine and the edges of the duct are sutured to it without piercing its lumen, with 2–3 sutures on each side. Next, the intestinal lumen is opened and the anastomosis is imposed with single-row interrupted sutures. In conclusion, the duct stump and anastomosis are invaginated into the intestinal wall, flashing the latter over the duct with separate interrupted sutures. Lastly, gastrojunoanastomosis is imposed according to the method of Hoffmeister-Finsterre. The stump of the resected stomach is partially sutured from the side of lesser curvature. The intestinal loop distal to pancreato- and choledochojejunoanastomoses is sutured to the gastric stump above the future anastomosis and gastrojejunoanastomosis is superimposed with a double-row suture [12].

 However, this method has several disadvantages: pancreatojejunoanastomosis is applied with capture of the Wirsung duct wall in the suture, the drainage tube (frame drainage) is not used, which leads to the development of anastomotic suture failure, choledochojejunoanastomosis is also imposed without external drainage and with seizure of the duct wall, which leads to the development of the structure of the anastomosis. Gastroejunoanastomosis is applied according to the method of Hoffmeister-Finsterre, which creates the conditions for refluxing gastric contents to the pancreatojejunoanastomosis zone.

 The problem solved by this invention is to reduce the risk of developing inconsistency of the sutures of pancreatic neuroanastomosis, the occurrence of acute pancreatitis and pancreatic necrosis, the formation of the structure of the anastomosis, the risk of developing reflux cholangitis, the formation of the structure of choledochojejunoanastomosis.

 New in the proposed method is that they impose a pancreaticunal anastomosis with invagination of the stump of the pancreas into the lumen of the jejunum on the frame drainage, one end of which is inserted into the lumen of the Wirsung duct, fixing it with a ligature, and the second is passed through a single-row suture of the intestinal lumen, gastrojejunostomy the esophagus, and bring it out through the nose, gastrojejunoanastomosis is imposed at the lesser curvature of the stomach, along the line of resection and form a “spur” at the greater curvature, the choledochojejunoanastomosis is imposed, invaginir I have a stump of the common bile duct in the intestinal lumen with two rows of gray-serous sutures on the walls of the common bile duct and intestines without stitching the mucous membranes so that the stump of the common bile duct hangs freely in the lumen of the intestine, and the common bile duct is drained by frame drainage through the intestinal lumen and an incision in the intestinal wall to the anterior abdominal wall .

 These distinguishing features are not found by the authors in the described literature and do not explicitly follow for a specialist from the prior art. This method has been clinically tested in the hospital surgery clinic named after A.G. Savinykh Siberian Medical University. Thus, the technical solution meets the criteria of the invention of "Novelty." "Inventive step", "Industrial Applicability".

 The problem is solved by pancreato-gastroduodenal resection, which consists in mobilizing the pancreatoduodenal complex, resection of the pancreatic head, duodenum, part of the stomach, in the application of end-to-end pancreatic-juvenile anastomosis, with invagination of the stump of the pancreas of the pancreas of the jejunum on the frame drainage, one end of which is inserted into the lumen of the Wirsung duct, fixing it with a ligature, and the second is carried out through a single-row (mechanically ii) a suture of the intestinal lumen, gastrojejunanastomosis, stomach, esophagus, and bring it out through the nose of the gastrojeanastomosis of the end-to-side type, superimposed in the lesser curvature of the stomach, along the resection line and forming a “spur” in the greater curvature of the stomach, choledochojejunoanastomosis of the type end to side ", invaginating the stump of the choledoch into the lumen of the intestine with two rows of gray-serous on the walls of the choledoch and intestines without stitching the mucous membranes so that the stump of the choledoch hangs freely in the lumen of the intestine, and the choledoch is drained by frame drainage through the intestinal lumen and incision in the intestinal wall to the front wall of the peritoneal.

The method is as follows:
An operational audit and mobilization of the pancreatogastroduodenal complex is performed.

 The mobilized complex is removed (resected).

Perform the reconstruction phase of the operation, which is performed as follows:
A pancreatojejunal anastomosis of the end-to-end type is applied with invagination of the pancreatic stump into the jejunum on the skeleton drainage with its passage through the intestinal lumen, through the gastroenteroanastomosis, stomach, esophagus and through the nose. The procedure for applying the anastomosis is as follows: after cutting the jejunum with the NLCA device and crossing the pancreas, the stump of the intestine with one row of the mechanical suture is brought to the gland stump; frame drainage is introduced into the lumen of the Wirsung duct in the form of a PVC pipe of the corresponding diameter, one end of which is strengthened with a ligature; the second end of this drainage is carried out through an opening in the center of a single-row (mechanical) suture into the lumen of the intestine, in the intestine itself it is hemmed with interrupted sutures to the capsule of the pancreas; the second row of nodal sutures, departing from the first by 2 cm, the stump of the gland is invaginated into the lumen of the jejunum.

 Impose gastroeyunoanastomosis of the type "end to side". The method of application is as follows: a loop of the jejunum is isoperistaltically sutured to the stomach stump along the resection line from the greater curvature of the stomach to the lesser, forming a “spur” at the greater curvature, and a double-row anastomosis is applied at the lesser curvature, through which the tube from the Wirsung duct is passed to bring it out through nose.

 Impose on the same loop of the intestine choledochojejunanastomosis type "end to side". The stump of the common bile duct is drained with a drainage tube and fixed with its ligature. A 0.5 cm incision is made in the intestinal wall through which this tube and common bile duct are drawn so that the stump of the common bile duct hangs in the intestinal lumen by 0.5 cm. Next, two rows of gray-serous sutures are placed on the walls of the common bile duct and intestine, invaginating the stump of the common bile duct in the lumen of the jejunum, without stitching the mucous membranes of the duct and intestines so that the stump of the common bile duct hangs freely in the lumen of the intestine. At a distance of 15 to 20 cm distal to the last anastomosis, two purse string sutures are placed on the intestinal wall, in the center of which an incision is made of the intestine, through which the tube is removed from the common bile duct, then the purse string sutures are tightened and the tube is brought to the anterior abdominal wall.

 A specific example of this operation.

 Patient Slabukhin V.M., 49 years old, case history N 375, was admitted to the hospital surgery clinic of the SSMU on 04/04/97 as an ambulance with a diagnosis of Pancreatic head cancer. Uncompensated stenosis of the duodenum. Complaints of daily vomiting, weakness, weight loss, pain in the epigastric region. Sick for 6 months.

 During the examination, the condition of the patient of moderate severity is extremely exhausted. Hyperfermentemin, there are no symptoms of diabetes. An X-ray and endoscopic examination of the gastrointestinal tract revealed a sharp narrowing of the antrum of the stomach and duodenum due to compression from the head of the pancreas. The data of ultrasound and relaxation duodenography reveal gross morphological changes in the head of the pancreas, presumably of a tumor nature.

 During surgery July 29, 1997, it was found that the head of the pancreas is a tuberous, stony density tumor-like formation that sharply narrows the duodenum. The body and tail of the gland are soft, not enlarged, with preserved longevity. The common bile duct is thin-walled, 1.0 cm in diameter, the gall bladder is enlarged, tense. Identified changes resemble a tumor in the head of the pancreas. It was decided to perform pancreato-gastroduodenal resection. The pancreatoduodenal complex with the tumor was mobilized. The stomach was crossed in the corner, the antrum was resected. The pancreas is crossed in the area and the isthmus, the main pancreatic duct (Wirsung duct) is revealed on the section. The jejunum is crossed by the NLCA device immediately below the Treytz ligament, is isolated, taken to the holders, the bile duct is crossed. Pancreatoduodenal complex with tumor removed. After this, end-to-end pancreatojejunoanastomosis was placed on the frame drainage, one end of which was inserted into the Wirsung duct and fixed by a ligature, and the second was drawn through an opening made in the center of a single-row mechanical suture into the jejunum and at a distance of 20 cm from the end of the intestine brought out through a 0.5 cm incision in the intestinal wall to the outside. The pancreatic stump is invaginated into the lumen of the jejunum by two rows of gray-serous sutures on the intestinal wall and the capsule of the gland. Then a double-row anastomosis of the end-to-side type was applied between the stump of the stomach and the loop of the jejunum at the exit site of the frame drainage, which was passed through the anastomosis, esophagus and out through the nose. Anastomosis is superimposed at the lesser curvature of the stomach, and the intestine along the line of resection with gray-serous sutures is sutured to the stump of the stomach, forming a "spur" at the greater curvature. Departing from the gastroeyunoanastomosis of 15 cm, a choledochojunoanastomosis of the end-to-side type was applied on the same loop of the intestine as follows: a frame drainage was introduced into the stump of the common bile duct in the form of a PVC pipe 0.9 cm in diameter and fixed to it with a ligature, an incision was made in the intestinal wall 0 , 9 cm and frame drainage and the stump of the common bile duct were conducted through it. Frame drainage removed from the lumen of the intestine at a distance of 20 cm through an additional incision in the wall of the intestine. Between the wall of the intestine and the wall of the common bile duct, gray-serous nodular sutures are placed at a distance of 0.5 from the edge of the bile duct, so that its stump hangs freely in the lumen of the intestine, the formation of an invagination choledochojejunoanastomosis is completed by the second row of gray-serous sutures. Frame drainage is fixed to the intestine with two purse string sutures and brought to the front abdominal wall. The abdominal cavity is sutured tightly.

 The postoperative period was uneventful, enteral nutrition was started on the 5th day, drainage from the common bile duct and Wirsung duct was removed at 3 weeks, sutures were removed on 9 days. 3 weeks after surgery, the patient was discharged in satisfactory condition, microjunostomy closed independently. The patient gained 7 kg in weight (weight before surgery 42 kg with an increase of 172 cm). When examining the patient one year after the operation, the last one does not show complaints, there are no dyspeptic phenomena, he does not receive replacement therapy, laboratory indicators are within normal limits. Weight - 63 kg.

 The proposed sequence of application of anastomoses reduces the risk of developing acute pancreatitis and pacreonecrosis due to the prevention of gastric contents entering the pancreatojejunoanastomosis zone, the application of an invagination, hanging anastomosis on the frame drainage reduces the risk of anastomosis suture failure and structure formation. The imposition of gastroeyunoanastomosis in the region of lesser curvature and the formation of a “spur” in the region of greater curvature prevents the gastric contents from entering the adduction loop.

 The imposition of a drooping choledochojejunanastomosis on the drainage reduces the risk of developing reflux cholangitis, the structure of the anastomosis.

 The positive effect of the proposed method consists in the methodology and sequence of the reconstructive stage of the operation, which is carried out in the following order: first, pancreatojejunoanastomosis is applied, then gastrojejunoanastomosis and finally choledochojejunoanastomosis. This arrangement of the anastomoses allows to exclude the throwing of bile and gastric contents into the pancreatojejunoanastomosis zone and into the pancreatic ducts, which is dangerous by the occurrence of pancreatic necrosis and insufficiency of this most vulnerable anastomosis. Invaginative pancreatojejunoanastomosis is applied without suturing the wall of the Wirsung duct to the intestine, forming it on the drainage, which ensures the outflow of pancreatic juice to the outside, excludes the entry of pancreatic enzymes into the anastomosis zone, reduces the load on the anastomosis sutures, and reduces the risk of suture failure. In addition, the application of anastomosis on the frame drainage reduces the risk of formation of the stricture of the Wirsung duct and the occurrence of obstructive pancreatitis. Gastroejunoanastomosis is applied at the lesser curvature, forming a “spur” at the greater curvature, which prevents food from entering the adductor loop and getting into the pancreatic ducts, which also prevents the development of acute pancreatitis and pancreatic necrosis. The technique of applying a choledochojejunoanastomosis provides areflux, which reduces the risk of anastomosis stricture formation and the development of cholangitis. Temporary external drainage of the common bile duct provides unloading of the common bile duct and reduces the risk of failure of anastomotic sutures.

Literature
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Claims (1)

 A method for pancreato-gastroduodenal resection, including mobilization of the pancreatoduodenal complex, resection of the pancreatic head, duodenum, single-stitched suture on the stump of the intestine, resection of a part of the stomach, end-to-end gastrocystic osteoarthritis, gastrointestinal end-to-side type, with invagination of the stump of the common bile duct in the intestinal lumen and drainage of the common bile duct, characterized in that they impose a pancreatojejunal anastomosis on the skeleton drainage, one end of which is inserted into the lumen of the Wirsung duct, fixing it with a ligature, and the second is passed through a single-row suture of the intestinal stump into its lumen, through gastroejunoanastomosis, stomach, esophagus and outward through the nose, while the sutured intestinal stump is sutured to the pancreatic capsule two rows of nodular gray-serous sutures, invaginating it, impose gastroyeyunoanastomosis at the lesser curvature of the stomach along the resection line and form a “spur” at the greater curvature of the stomach, apply choledochojunoanastomosis, invaginating the stump ha lumen in two rows of gray-serous seam on the wall of common bile duct and intestine mucous without crosslinking, so that the stump choledoch hangs freely into the lumen and choledoch drained carcass drainage conducted through the lumen and the incision in the intestinal wall to the abdominal wall.