RU2181027C1 - Surgical method for treating complicated chronic pancreatitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out pancreas head resection. Cicatricially changed portion of the pancreas is removed. Superior and inferior pancreaticoduodenal arteries are transected. EFFECT: enhanced effectiveness of surgical treatment of chronic pancreatitis, chronic duodenal impassability and choledochus stenosis. 2 dwg

Description

 The present invention relates to medicine, namely to surgery, and can be used in the surgical treatment of complicated chronic pancreatitis.

 The steady increase in the incidence of chronic pancreatitis (CP) has recently been of increasing interest, according to Worning (H. Incidence and prevalence of chronic pancreatitis. In: Beger HG, Buchler M., Ditschuneit H., Malfertheiner P., eds. Chronic pancreatitis Berlin: Springer-Verlag. - 1990. - P.8-14) 1990, 4 out of 100,000 residents have clinical manifestations of this pathology, mainly among young and middle-aged people.

Complications of CP are an unconditional indication for surgical treatment (Nesterenko Yu.A., Glabay V.P., Shapovalyants S.G. // Chronic pancreatitis. -M .: Russia, 1997. - 173 p.)
Recent studies, taking into account the embryogenetically determined anatomical heterogeneity of the pancreas (pancreas), as well as new data on regulatory relationships in the duodenopancreatic complex (Korotko G.F., Rogal M.L., Orlovsky A.V., Gladky E.Yu. Novaya the paradigm of urgent adaptation of pancreatic enzyme secretion "// Mat. ХVII All-Russian Conf." Physiology and Pathology of Digestion ", dedicated to the 150th anniversary of the birth of IP Pavlov. - Krasnodar, 1999.-S.21-22 ) allow us to talk about the special significance of the duodenum (duodenum) and the need to maximize the conservation of this portion of the gastrointestinal tract in the surgical treatment of complicated KP.

One of the complications of CP is chronic duodenal obstruction as a result of massive parapancreatic and periduodenal fibrosis (Danilov M.V., Fedorov V.D. Pancreas surgery. M .: "Medicine", 1995. - 511 p.). Moreover, in patients requiring surgical treatment, the frequency of duodenal stenosis with severe clinical symptoms increases to 15% (Warshaw AL, Rattner DW Timing of surgical drainage for pancreatic pseudocyst // Ann Surg. - 1985. - V.252. - P.720 -724)
However, the literature data do not describe methods of surgical treatment of CP with resection of the affected pancreatic segment that eliminates duodenal and biliary stenosis, and intersection of the upper pancreatoduodenal arteries and the preservation of the descending and lower horizontal branches of the duodenum, as well as the intersection of the lower pancreatoduodenal arteries with preservation of the upper sections of the DPC.

 As an analogue, a pyloropreserving pancreatoduodenal resection (PSPDR) was taken.

 Pancreatoduodenal resection as an surgical intervention in the treatment of complicated CP has been used for a long time, since it solves the main tasks: eliminating pain, eliminating biliary and duodenal stenosis. The operation in the description of Traverse and Longmyre (1977) (cited Danilov M.V., Fedorov V.D. Pancreatic surgery. M.: “Medicine”, 1995. - 511 p.) Consists of three sequentially performed steps: 1) operating revision and allocation of pancreatoduodenal complex; 2) removal of a block of organs; 3) reconstruction phase.

 As an operative access, a wide median laparotomy is performed with hardware correction of the operative access by Seagal expanders. As with surgery for tumors, in the first stage of pancreatoduodenal resection performed for complicated pancreatitis, an in-depth audit of the entire gastropancreatoduodenal complex, liver and biliary tract, retroperitoneal fiber is carried out, assessing primarily the technical feasibility of the operation. In a number of cases, the right corner of the colon is preliminarily separated by acute route, Kocher is mobilized according to Kocher, and they enter the gland bag along the line of attachment of the posterior leaf of the greater omentum to the transverse colon in an acute way, which greatly facilitates intraoperative revision. With CP, the commissural-infiltrative process around the pancreas and inflammatory infiltration of the surrounding pancreatic tissues are especially pronounced, which makes the stage of isolation of the gland and duodenum more traumatic. For the final isolation of the duodenum and pancreatic head, the middle colon artery is located and, guided by it and keeping it constantly under control, the right half of the mesentery of the transverse colon intersects. The peritoneum of the hepatoduodenal ligament is dissected and its elements are dissected, shifting all fiber and lymph nodes to the pancreatic head. The peritoneum is cut along the upper edge of the pancreas and enters with the index finger behind the gland at the level of the neck. The index finger of the second hand goes towards the bottom up between the mesenteric vein and the posterior surface of the gland. Tunneling is carried out with great care so as not to damage the small venous trunks coming from the pancreas to the portal vein. After isolating the isthmus of the gland, a catheter or braid is held under it.

 Then proceed to the second stage - the allocation of pancreatoduodenal complex. The gastroduodenal artery intersects. When carrying out PSPDR for CP, there is no need for resection of the stomach, therefore, they preserve pyloric pulp and cross the duodenum 1.5-2.0 cm distal to the pylorus, the stomach is diverted to the right. The common bile duct cross below the inflow of the cystic duct. The cystic duct is left for decompression of the biliary tract by applying an external cholecystostomy. With a low inflow of the cystic duct, the hepatic duct crosses above the cystic. In this case, a cholecystectomy is performed. Cross the initial section of the jejunum. The leading loop of the intestine is sutured tightly and, isolating it, is removed from under the mesenteric vessels. On the back surface of the main trunk of the superior mesenteric artery, the main trunk of the lower pancreatoduodenal artery is found and ligated. The gland is crossed in the area of its isthmus, slightly to the left of the superior mesenteric vein and to the right of the confluence of the splenic vein into the portal. Behind the isthmus of the gland there are usually no vessels, and dissection of its tissue is less dangerous. In the cult of the pancreas, the main pancreatic duct is found, it is captured by two thin threads on an atraumatic needle. Produce hemostasis by applying U-shaped sutures to the stump of the gland. After all of the above measures, the drug remains on the hooked process of the pancreas. The hook-shaped process is firmly fixed by its own ligament to the retroperitoneal fascia. Pulling it towards himself, the surgeon ligates it and cuts it off. The drug is removed.

 After that, they begin the reconstructive phase of the operation. First of all, they restore the passage of pancreatic juice - the creation of pancreatojejunal anastomosis. Distal is created choledochojejunal anastomosis of the type end-to-side. The last and most distal is superimposed direct duodenojejunoanastomosis (Braasch J. et al., 1991).

disadvantages
1. Remove the important sensory and regulatory part of the duodenopancreatic complex - duodenum.

 2. Unreasonably increase the volume of surgery for inflammatory diseases of the pancreatoduodenal complex.

 The second analogue we chose economical pancreatoduodenal resection according to N.S. Makohe.

 As an operative access, a wide median laparotomy is performed with hardware correction of the operative access by Seagal expanders. After exposure of the pancreatoduodenal zone through the posterior sheet of the peritoneum, in the middle of the descending section of the duodenum, ligatures-holders are applied (at the level of the palpable large duodenal papilla). Pulling anteriorly behind the ligatures, produce KDP from loose retroperitoneal fiber. Next, duodenotomy is performed in an oblique direction, then the lower incision line and resection of the adjacent part of the pancreatic head for 1-1.5 cm. The distal sections of the pancreatic and common bile ducts are intersected along the pancreatic head resection line, followed by a wedge-shaped excision of the posterior duodenal wall in a single block with a large duodenal papilla. The stumps of the ducts are stitched together by 2-3 nylon sutures. The prosthetics of the ducts are carried out by polyethylene tubes according to their diameter and the fixing of the outgoing drainage tubes with a thin catgut. The wound of the posterior wall of the duodenum is sutured with a single intra-nodular suture of Mateshuk. Prosthetic stumps of the common bile and pancreatic ducts are sewn into the suture line of the posterior medial wall of the intestine. The wound of the anterior wall is sutured with a double-row suture. The line of nodal silk sutures of the second row continues to the wound of the pancreatic stump. Nodal silk sutures - on the posterior sheet of the peritoneum and the root of the mesentery of the colon.

disadvantages
1. The operation is designed as palliative in the treatment of periampicular cancer and does not solve the issue of removing the entire pathological focus in the pancreas.

 2. Not in all cases it is possible to stop duodenal and biliary obstruction.

 An operation was taken as a prototype - sectoral resection of the pancreas with preservation of duodenum.

 Sectoral resection of the pancreas is technically more complicated, but more modern surgical intervention in the treatment of CP proposed by Beger (cited by Danilov M.V., Fedorov V.D. Pancreatic surgery. M.: "Medicine", 1995. - 511 p. ) Preservation of the duodenum and common bile duct improves the functional state of the gastrointestinal tract and the quality of life of patients in the postoperative period. The technique of such surgery has its own characteristics. Just as with pancreatoduodenal resection, the right corner of the colon is preliminarily separated, KDP is mobilized, and they enter the omental bursa sharply along the line of attachment of the posterior leaf of the greater omentum to the transverse colon. In the classic version, the mobilization of the duodenum is not performed in order to preserve its regional blood supply. In case of mobilization of the duodenum according to Kocher, it is necessary to leave at least 2 cm of parenchyma along the inner edge of the duodenum (the intrapancreatic part of the common bile duct and the anterior branch of the upper and lower pancreatoduodenal arteries pass here). The stage of the subtotal medial pancreatic resection proper begins with the intersection of its isthmus over the mesenteric portal venous trunk, after which hemostasis is performed on a section of the distal stump of the gland by applying thin, puncturing sutures to it. The head of the gland, together with the duodenum, is turned to the right and separated from the right edge of the trunk of the superior mesenteric and portal veins, bandaging small vascular branches flowing into it. Next superimposed supraduodenal choledochoduodenal or choledochojejunoanastomosis.

 The reconstructive stage of the operation includes, first of all, the creation of an anastomosis of the distal pancreatic stump with an isolated loop of jejunum along the Ru type of end to end or end to side. Next, the application of interintestinal anastomoses is performed.

disadvantages
1. This operational method does not resolve chronic duodenal obstruction when involved in the inflammatory-cicatricial process of the walls of the duodenum.

 2. This method of surgical treatment does not take into account sensory-effector relationships in the pancreatoduodenal complex.

The purpose of the invention
Based on new data on sensory-effector relationships in the pancreatoduodenal complex, we propose a method for the surgical treatment of complicated CP, chronic duodenal obstruction and fibrosing stenosis of the common bile duct, which eliminates duodenal and biliary obstruction, including the preservation of the vertical and lower horizontal branches of the duodenum and the intersection of the upper pancreas.

Tasks
1. To develop a method for removing the affected part of the pancreatic head and the upper horizontal branch of the duodenum.

 2. To develop and justify the technical feasibility of maintaining blood supply to the duodenum in the lower pancreatoduodenal arteries after resection of the pancreatic head with the upper horizontal part of the duodenum.

 3. To develop a method for removing the affected part of the pancreatic head and the lower horizontal branch of the duodenum.

 4. To develop and justify the technical feasibility of maintaining blood supply to the duodenum in the upper pancreatoduodenal arteries after resection of the pancreatic head with the lower horizontal part of the duodenum.

 The essence of the proposal is that the pancreatic head affected by the fibrotic process is resected with the sector involved in the fibrosing process of the duodenum and the intrapancreatic part of the common bile duct. In this case, the blood supply to the remaining part of the duodenum occurs through the lower or upper pancreatoduodenal arteries, which allows you to save the sensory areas of the duodenum.

 The method is as follows.

Expanded median access is performed with excision of the xiphoid process and intersection of the cartilaginous part of the X-XI ribs at the top and continue 5-6 cm down from the navel, bypassing it to the right. Sigal type extenders are installed, and traction is carried out on both sides by the right and left costal arches until the front sections of the dome of the diaphragm take a position at an angle of 90 ^o to the frontal plane. To the edges of the wound, avoiding drying out during a long operation, wet gauze wipes are hemmed. Then the organs of the gastro-pancreatoduodenal zone are mobilized: a large omentum is separated from the transverse colon throughout the entire length - from the hepatic angle to the splenic bend. The mesocolon is especially precisely separated from the pancreatic head and the hook-shaped process. In some cases, the cavity of the small omentum is sealed throughout the inflammatory-adhesion process, while the front surface of the pancreas is bluntly and sharply separated from the posterior wall of the stomach. Mobilize the duodenum according to Kocher. This stage is necessary even in cases where further manipulations will be performed on the distal pancreas for several reasons: the mobilization performed allows you to palpate the condition of the head, distal choledochus, facilitates further hemostasis and relieves the symptoms of duodenal obstruction if the scar-inflammatory process does not affect the duodenal layers . Next, the hepatoduodenal ligament is mobilized - the state of its elements is assessed.

 1. The first method of surgical treatment is used for lesions of the pancreatic head and body of the pancreas, stenosis and deformity of the duodenum in the area of the bulboduodenal sphincter, stenosis of the intrapancreatic part of the common bile duct and involvement of the gastroduodenal and hepatic arteries in the inflammatory process. A prerequisite for a successful operation is the presence of good blood flow through the lower pancreatoduodenal arteries.

 After mobilization of organs, the pancreas is crossed at the level of the isthmus. If the superior mesenteric and portal vein is involved in the fibrous process, sometimes circularly, then tunneling under the isthmus of the pancreas is impossible and the pancreas is intersected between the pre-ligated sections of the pancreatic tissue, isolating the superior mesenteric vein from adhesions and adhesions in stages. After crossing the pancreas, the border of the pancreatic head resection is outlined, which runs strictly parallel to the medial edge of the duodenum, due to the peculiarities of the location of the arterial network at a distance of 5-8 mm from the duodenum wall. The duodenum meets at the level of the bulboduodenal sphincter, the duodenal bulb is separated from the head of the pancreas. At the pylorus level, the right gastro-omental artery and vein are crossed 1-2 cm below the pylorus to preserve the lower pyloric artery and vein, then the bulb with the pylorus is brought up, leaving it fixed on the preserved right gastric vessels - arteries and veins, while it is necessary to save the bulb pyloric vessels. After that, the hepatic artery is skeletonized by the hepatoduodenal ligament, while gastroduodenal is ligated. In the superior mesenteric vein towards the portal vein, the upper pancreatoduodenal arteries cross from below.

 The lateral border of the resection of the pancreatic head in the upper segment is the choledoch wall, which, when the head is resected, is gradually released from inflammatory scars and adhesions. At the same time, biliary hypertension is eliminated. If the lumen of the common bile duct is not determined throughout, the bile duct crosses as close as possible to the duodenum, and mobilize to the cystic duct, the diameter of the common bile duct is usually wide (pre-stenotic expansion) due to prolonged severe scar inflammation.

 Next, the reconstructive stage is carried out, based on the reconstruction of the conceptual pancreatoenteroanastomosis (PEA) on the distal stump of the pancreas, restoration of duodenum continuity by applying an anastomosis between its distal and proximal parts.

 The final view of the pancreatoduodenal complex after resection of the pancreatic head with excision of the upper pathologically altered segment of the duodenum, intersection of the upper pancreatoduodenal arteries and preservation of the lower pancreatoduodenal arteries is presented in figure 1.

 2. The second method of surgical treatment is used for lesions of the pancreatic head and body of the pancreas, stenosis and deformation in the area of the descending and lower horizontal branches of the duodenum, stenosis of the intrapancreatic part of the common bile duct and involvement of the lower pancreatoduodenal arteries in the inflammatory process. A prerequisite for a successful operation is the presence of good blood flow through the upper pancreatoduodenal arteries.

 The intersection and resection of the pancreatic head is carried out according to the same principles as in the first case, with the difference that the fibrous process mainly affects the pancreatic head with a hook-shaped process, extending to the descending or lower horizontal branch of the duodenum, while the duodenum intersect at the maximum its lesions with fibrosis and are released in the proximal and distal directions from scars and adhesions, places where the release of the duodenum is impossible due to the prevalence of the process in depth, is resected to the border of healthy tissue. In the future, the removal of the hooked process with the intersection of the lower pancreatoduodenal vessels is performed. If the distal part of the duodenum is blocked in the area of the mesentery root by a peri-inflammatory process, the duodenum is removed from under the mesentery root.

 The reconstructive stage of this method for performing proximal pancreatic resection includes conceptual pancreatoenteroanastomosis with the creation of duodenal passage continuity.

 The final view of the pancreatoduodenal complex after resection of the pancreatic head with excision of the lower pathologically altered segment of the duodenum, intersection of the lower pancreatoduodenal arteries and preservation of the upper pancreatoduodenal arteries is shown in Fig.2.

 The proposed method for the surgical treatment of complicated chronic pancreatitis radically eliminates the existing complication of chronic pancreatitis while preserving the functionally active sensory fields of the remaining part of the duodenum, which allows implementing adaptive-compensatory mechanisms of pancreatic secretion in the early and long-term postoperative period after pancreatic resection.

The method was tested on 9 patients in the conditions of the Russian Center for Functional Surgical Gastroenterology:
Example 1. Patient G., 39 years old, was admitted to the clinic RCSCH 15.07.99g. with a diagnosis of Chronic continuously recurring pseudotumor pancreatitis with symptoms of exocrine insufficiency, obstructive jaundice, duodenal obstruction, severe pain. Considers himself ill for about 5 years, has repeatedly been treated conservatively. Last exacerbation about a month ago. On admission, herpes zoster, nausea, vomiting, jaundice bothered. Weight loss of 10 kg for 3 years. On ultrasound, the above diagnosis is confirmed. Patient 07/18/99 surgical treatment was performed in the amount of resection of the pancreatic head with excision of the scar-changed area of the upper part of the vertical branch of the duodenum and preservation of the common bile duct. During surgery, all pathologically pancreatic tissue sections altered by fibrotic transformation were removed. The postoperative period was uneventful. Discharged from the hospital on day 16 in satisfactory condition. At the follow-up examination after 6 months, the patient recovered by 5 kg. No complaints.

 Example 2. Patient P., 47 years old, was admitted to the clinic on 06/17/99. with complaints of weight loss of about 10 kg, of girdle pain, worse after eating, lack of appetite, nausea. After a set of diagnostic measures (ultrasound, RCP, laboratory tests), a clinical diagnosis was made: Chronic calculous pancreatitis with exocrine insufficiency, with symptoms of partial duodenal obstruction in the lower horizontal branch of the duodenum, severe pain. After appropriate preoperative preparation, the patient underwent surgical treatment in the amount of pancreatic head resection with excision of the scar-changed sector of the lower horizontal part of the duodenum and the intersection of the lower pancreatoduodenal arteries. At the same time, the upper and descending parts of the duodenum with good blood supply to the upper pancreatoduodenal arteries are preserved. The postoperative period was uneventful. The patient was discharged on the 15th day. At the follow-up examination after 6 months, the patient has no complaints, recovered by 3 kg. Ultrasound - the distal part of the pancreas compared with the previous study without inflammation.

 The developed method for the treatment of complicated chronic pancreatitis allows, from a physiological point of view, to objectify and justify the tactics of surgical treatment, to reduce the rehabilitation and treatment time for this category of patients.

Claims (1)

 A method of surgical treatment of complicated chronic pancreatitis, including a resection of the pancreatic head, characterized in that a scar-modified part of the duodenum is excised with the condition of crossing the upper or lower pancreatoduodenal arteries.

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