RU2197904C2 - Method for pancreatojejunoanastomosis at pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: ansa of small intestine is formed, its end should be sutured tightly. An arch is formed by using sutured ansa with diameter being larger against that of pancreatic stump. "Fenestra" is cut in vessel-free part of intestinal arch mesentery. Glandular stump is fixed along circumference to "fenestrum" edges and intestinal serosa. Subsequent anastomosis covering is carried out by suturing serosa of intestinal ansa arms by not capturing pancreatic tissue. The method provides prophylaxis of pancreatojejunoanastomosis failure. EFFECT: higher efficiency of operation. 7 dwg

Description

 The proposed method relates to medicine, namely to oncology and pancreatic surgery, and can be used in the surgical treatment of cancer of the head of the pancreas, cancer of the Vater nipple and terminal portion of the common bile duct, cancer of the stomach with germination in the head of the pancreas, chronic pain pseudotumor pancreatitis when performing radical surgical intervention - pancreatoduodenal or pancreatogastroduodenal resection.

 Currently, due to the success of the development of surgery, anesthesiology and resuscitation, pancreatoduodenal resection has become more common than before. The development of technical aspects and the improvement of the possibilities of postoperative management of patients made it possible to significantly reduce postoperative mortality during this intervention, but pancreatojejunal anastomosis continues to be the “cornerstone” of pancreatoduodenal resection [1, 2, 3, 4], which accounts for the largest percentage of postoperative complications.

 The complexity of the solution to this problem is evidenced by the large number of proposed methods of pancreatojejunostomy, of which none is absolutely reliable. "Many authors (Codivilla, Whipple, Brunschwig and others) believe that it would be wiser to refuse to impose this anastomosis" - quote from the source [3]. For this reason, a number of authors [2] refuse to perform this anastomosis due to the high risk of complications, filling the pancreatic ducts or suturing the pancreatic stump tightly, which however often leads to postoperative pancreatic necrosis, and with a favorable outcome of the operation, exocrine pancreatic function is completely excluded .

 Other authors, for the same reason, resort to pancreatoduodenectomy [3], which forces a substitution of insulin therapy for life or a heterotopic pancreas transplantation for a favorable outcome of the operation, which significantly increases the material costs and inconvenience associated with the constant use of insulin. Thus, the development of a method of pancreatojejunostomy, which reduces the risk of anastomotic insufficiency to a minimum, would be the most optimal solution.

 The closest in the set of essential features to the proposed method is the method of pancreatojejunoanastomosis with pancreatoduodenal resection according to A.A.Shalimov [4], which is selected by the authors as a prototype.

 The known method is as follows. A loop of the small intestine is formed, the leading end of which is partially sutured, then the mobilized stump of the pancreas is stitched together with a previously opened lumen of the loop of the small intestine, followed by covering the anastomosis zone with sections of the leading and discharging loops of the small intestine stitched together. The known method allows you to perform pancreatoduodenal anastomosis with pancreatoduodenal resection.

 However, after such an operation, the risk of insufficiency of pancreatojejunal anastomosis remains, since with a small diameter of the adducting and diverting small intestine, reliable sheltering (without tension of the joints) of the anastomosis zone is not always possible, which can lead to eruption of the joints and the occurrence of peritonitis.

 The objective of the proposed method is to reduce the likelihood of complications (insufficiency of pancreatojejunoanastomosis) during pancreatoduodenal resection.

 The problem is solved by the proposed method, including the formation of a loop of the small intestine, suturing the adducting loop of the small intestine, stitching the mobilized stump of the pancreas with a previously opened lumen of the loop of the small intestine, followed by covering the anastomosis zone with sections of the leading and discharging loops of the small intestine stitched together, according to which suturing the adducting loop of the small intestine is performed tightly, the adducing loop intersects below the sutured part of the small intestine, from the sutured loop of the small intestine I form an arc with a diameter greater than the diameter of the pancreatic stump, before stitching the mobilized pancreatic stump with a previously opened lumen of the small intestine, a “window” is cut through the avascular section of the mesentery of the small intestine, which forms an arc, through which the stump of the pancreas is pulled by capsule stitches sewn along the edges and fix the stump of the pancreas around the circumference of the capsule of the gland to the edges of the “window” of the mesentery and serosa of the intestine, hemming the leading end of the intestine to the circular outlet around the stump of the gland, and the next shelter is carried out by stitching serosa of the leading and outlet loops of the small intestine over the anastomosis without trapping the pancreatic tissue.

 A distinctive feature is that suturing the adducting loop of the small intestine is performed tightly, the advancing loop intersects below the sutured part of the small intestine, and from the sutured loop of the small intestine an arc is formed with a diameter larger than the diameter of the pancreatic stump, before stitching the mobilized pancreatic stump with a previously opened lumen , in the non-vascular section of the mesentery of the small intestine, forming an arc, cut out a "window" through which the stump of the pancreas is pulled by the capsules sewn along the edges We hold and fix the pancreatic stump around the capsule of the gland to the edges of the “window” of the mesentery and intestinal serosa, suturing the leading end of the intestine to the outlet leading circularly around the stump of the gland, and the subsequent covering is done by stitching serosa of the leading and outgoing loops of the small intestine over the anastomosis without trapping the tissue pancreas.

 Suturing the leading end of the loop of the small intestine allows avoiding the entry of intestinal contents to the anastomosis zone, holding the pancreatic stump through the “window” of the mesentery of the small intestine contributes to more reliable isolation of the anastomosis from the free abdominal cavity due to the additional covering of the mesentery of the intestine, as well as a more reliable shelter of the anastomotic zone leading and diverting loops of the small intestine, regardless of the diameter of the small intestine involved in the anastomosis, sheltering the front wall of the intestine without trapping the pancreatic tissue lezy reduces pancreatic trauma and reduces the risk of eruption of sutures.

 Analysis of scientific, technical and patent information showed that the proposed method is new and meets the criterion of "inventive step".

 The proposed method is as follows. After performing the resection stage of the gland, one of the generally accepted methods proceeds to the reconstructive stage of the operation. A loop of jejunum up to 40-50 cm long is isolated in Ru. The end of the intestine is sutured according to the usual method (UKL-40, half-net and gray-serous sutures). The end of the loop is bent in the form of an arc so that the length of the knee is 2-3 cm longer than the length of the vertical section of the pancreatic stump. After that, a “window” is cut out in the avascular section of the mesentery enough to hold the pancreatic stump (sometimes 1-2 radar branches have to be crossed without compromising the blood supply to the small intestine). Then the pancreatic stump, previously mobilized 1.5-2 cm from the marginal vessel (the parenchyma of the gland after mobilization should bleed, after which hemostasis is performed), are sewn around the edges for a capsule on two holders. The holders are held through the “window” of the mesentery and for them through the “window” stretches the pancreatic stump.

 The stump of the gland is fixed around the circumference of the capsule to the serous membrane and mesentery of the intestine with several (6-8) interrupted sutures. The end of the muffled loop of the small intestine is fixed to the outlet loop circularly around the pancreatic stump. Then, a longitudinally diverting loop of the small intestine is dissected with an electrocoagulator or scalpel over a slightly larger diameter of the pancreatic stump. After this, the edges of the pancreatic stump are sutured with the open lumen of the small intestine by interrupted sutures, while the stump of the gland is immersed in the lumen of the opened small intestine. Then, starting from the bottom corner, the outlet and lead loops of the small intestine are sutured with nodular gray-serous sutures without trapping the gland tissue.

The proposed method is illustrated in figures 1-7, where:
figure 1:
1 - pancreatic stump
2 - cut "window" in the mesentery of the small intestine
3 - sutured tightly leading end of the loop of the small intestine;
figure 2 - holding the stump of the pancreas through the "window" of the mesentery of the small intestine;
figure 3:
1 - pancreatic stump
2 - opened for stitching the lumen of the small intestine;
in FIG. 4 - stitching of the lumen of the small intestine with a stump of the pancreas;
in FIG. 5 - stitching of the pancreatic stump with the lumen of the small intestine is completed;
figure 6 - sewn sections of the leading and discharging loops of the small intestine over the anastomosis area without capturing pancreatic tissue;
Fig.7 is a General diagram of pancreatoduodenal resection according to the developed method, where:
1 - pancreatic stump
2 - zone of pancreatoeunoanastomosis
3 - spleen
4 - stomach stump
5 - liver
6 - hepaticoyunoanastomosis
7 - a loop of the small intestine cut along Ru, participating in the creation of pancreatojejunostomy
8 - gastroyunoanastomosis
9 - jujunostomy.

 The proposed method was developed on 10 corpses, then tested in an experiment on 8 outbred dogs.

 In the clinic, the proposed method treated six patients. Three patients were diagnosed with pancreatic head cancer, two patients with stomach cancer sprouting into the pancreatic head, and one patient with Vater's nipple cancer.

 One patient died of acute cardiovascular failure 10 hours after surgery for extensive gastric cancer: after gastropancreatodudenal resection, right-sided hemicolectomy, R3 limadenectomy (there was no abnormal fluid in the abdominal cavity, 150 ml of blood was allocated for drainage). One patient had a subhepatic abscess outside the anastomosis zone - after opening the abscess, a slow recovery began.

 The remaining patients were discharged with a relatively smooth postoperative course.

EXAMPLES OF SPECIFIC EXECUTION OF THE SUGGESTED METHOD
Example 1
Patient L., 42, N IB 4871, was admitted to the hospital N 30 05.11.96 with a diagnosis of Pancreatic head cancer, obstructive jaundice. 11/08/96 performed laparoscopic cholecystostomy. 11/26/96 operation: gastropancreatoduodenal resection with plastic surgery of the superior mesenteric vein (V.V. Ershov).

 Upper median laparotomy. During revision, a tumor of 12 • 10 cm of the pancreatic head with germination of the superior mesenteric vein in a 2 • 1 cm area. The gastropancreatoduodenal complex was mobilized typically with excision and local plastic surgery of the superior mesenteric vein. Resection on the line of mobilization. A loop of the small intestine was formed according to Ru with suturing of the distal end tightly with the UO-40 apparatus with purse-string and gray-serous sutures. An arch with a diameter greater than the diameter of the stump of the gland is formed at the end of the loop of the jejunum that is sutured tightly. A “window” is made in the mesentery of this gut, through which a stump of the pancreas previously taken on the holders is drawn. The pancreatic stump is circularly fixed with gray-serous sutures to the edges of the “window” of the mesentery and intestinal serose, the end of the loop of the small intestine sewn tightly is hemmed circularly to the outlet loop around the stump. The intestinal lumen was opened longitudinally on the discharge part of the arc. The pancreatic stump is sewn with interrupted sutures into the open lumen of the intestine. After that, the leading and abducting knees of the intestine are stitched with nodular gray-serous sutures over the anastomosis. At 20 cm from pancreatojejunoanastomosis, end-to-side choledochojejunoanastomosis was performed after cholecystectomy and choledoch drainage according to Pikovsky. End-to-side gastroenteroanastomosis, anastomosis of the loop carrying pancreatojejunoanastomosis with jejunum stitched to the end-to-side stomach. Drainage. Suture of the wound.

 Histology 6867, dated 11/28/96: Parenchymal cancer of the pancreas of the alveolar-trabecular structure, infiltration of the wall of the duodenum.

 Smooth postoperative course. 12.16.96 in satisfactory condition the patient was discharged home.

Example 2
Patient B., 60 years old. N IB 3271, was admitted to the c / o b-ts N 30 07.07.97 with a diagnosis of Cancer of the pancreatic process. According to CT and ultrasound, the tumor is 50 • 60 mm in diameter, localized in the projection of the body and the hooked process of the pancreas. The patient is concerned about severe pain in the mesogastric and lumbar region, poorly stopped by non-narcotic analgesics. Operation July 15, 1997 (V.V. Ershov). Gastropancreatoduodenal resection.

 Upper median laparotomy with a continuation of the incision 4 cm below the navel. During the audit, distant metastases were not detected. Gastrointestinal ligament opened. There is a dense tuberous tumor emanating from the hooked process of the pancreas, passing to the body and head 60 • 70 mm in diameter, clutch-like covering the superior mesenteric vessels. In the hepatoduodenal ligament - a dense elastic lymph node up to 2 cm in diameter. Pancreatoduodenal complex and 1/2 stomach were mobilized with technical difficulties, a small part of the superior mesenteric vein with local plastic surgery and adventitia of the superior mesenteric artery were resected due to the ingrowth of the tumor (there is no complete confidence in the radicalness of the operation, the resection was performed due to the pronounced preoperative pain syndrome and relatively young patient). A single block removed the lymph nodes of the hepatoduodenal ligament, paracaval and paraaortic lymph nodes. The stump of the stomach is sutured with the TL-60. The stump of the small intestine 10 cm below the Treytz ligament is sutured with the UO-40 device with immersion in purse-string and gray-serous sutures.

 At 40 cm of the sutured end, the small intestine, after a small mobilization of the mesenteric margin, was crossed by the UO-40 apparatus, immersed in purse-string and gray-serous sutures, and after performing pancreatic choledochojejunostomy, a typical end-to-side anastomosis with stump of the stomach was performed anteriorly. Initially, postneoplastic pancreatojejunoanastomosis was performed. For this, an arc with a diameter greater than the diameter of the stump of the gland is formed on the sutured tightly and crossed loop of the jejunum. In the mesentery of this gut, a "window" is cut through which a pancreatic stump previously taken on the holders is drawn. The pancreatic stump is circularly fixed with gray-serous sutures to the edges of the “window” of the mesentery and intestinal serose, the end of the loop of the small intestine sewn tightly is hemmed circularly to the outlet loop around the stump. The intestinal lumen was opened longitudinally on the discharge part of the arc. The pancreatic stump is sewn with interrupted sutures into the open lumen of the intestine. After this, the leading and abducting knees of the intestine are stitched with nodular gray-serous sutures over the anastomosis without capturing the pancreatic parenchyma. Then, 20 cm from pancreatojejunoanastomosis, choledochojejunoanastomosis was performed (cholecystojejunoanastomosis is impossible due to low inflow of the cystic duct stump - forced cholecystectomy) "end to side" - dexon 4/0. A loop of the jejunum 20 cm from the choledochojejunoanastomosis is sewn into the end-to-side jejunal loop of the jejunum anastomosed with the stomach. Suturing mesentery windows. Control of hemostasis. Trap drains into the right subhepatic space and left subphrenic space. Suture of the wound of the abdominal wall. Discharged on August 18, 1997 in satisfactory condition.

 As can be seen from the obtained results, the proposed method allowed to reduce the risk of postoperative complications with pancreatoduodenal resection, in particular, to prevent the occurrence of insufficiency of sutures of pancreatojejunoanastomosis and thereby reduce postoperative mortality.

Sources of information
1. Kochiashvili V.I. Atlas of biliary tract surgery. - M .: Medicine, 1971, 208 p.

 2. Kuzin M.I., Danilov M.V., Blagovidov D.F. Chronic pancreatitis. - M .: Medicine, 1985, 368 p.

 3. Surgical surgery. / Under the general ed. prof. I. Littman, from Acad. n-uk Hungary, Budapest, 1981, 1175 p.

 4. Prototype: Shalimov A. A., Radzikhovsky A. P., Polupan V. N. Atlas of operations on the liver, biliary tract, pancreas and intestines. - M .: Medicine, 1979, 214 p.

Claims (1)

 The method of pancreatojejunoanastomosis in pancreatoduodenal resection, including the formation of a loop of the small intestine, stitching of a mobilized pancreatic stump with a previously opened lumen of the small intestine, followed by covering the anastomosis zone with sections of the small intestine stitched together, which form the loop of the small intestine end tightly, from a tightly sewn loop of the small intestine form an arc with a diameter larger than the diameter of the pancreatic stump, before stitching the mobilized pancreatic stump gland with a previously opened lumen of the small intestine, in the non-vascular section of the mesentery of the small intestine, which forms an arch, cut out a “window” through which the stump of the pancreas is pulled by the holders stitched over the edges of the capsule and the gland stump is fixed around the capsule to the edges of the “mesentery window” and to intestinal serosa, hemming the end of the small intestine that is sutured tightly to the outlet, and the subsequent covering of the anastomosis is carried out by stitching together serous knees of the intestinal loop without trapping the pancreatic tissue.

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