RU2217079C1 - Method for restoring biliary duct continuity after extensive hepaticodochotomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves transferring pancreas head into portal fissure after having done extensive hepaticodochotomy by transecting proper ligament of uncinate process. End-to-end hepaticocholedochoanastomosis is created. The hepaticocholedochus is drained via the left hepatic duct and round ligament of the liver. EFFECT: reduced risk of hepaticocholedochus suture inconsistency.

Description

 The invention relates to medicine, in particular to reconstructive surgery of the extrahepatic bile ducts during resections of hepatic choledochus for diseases associated with impaired patency while maintaining the function of the large papilla of the duodenum.

 Known methods of biliodigestive anastomoses.

 The disadvantage of this method is a violation of the physiology of bile excretion, disabling the function of the large papilla of the duodenum 12 from the passage of bile with the cessation of the portioned supply of bile into the gastrointestinal tract.

 Among them, the most famous is the method of supraduodenal choledochojejunostomy according to Jurash, which is often accompanied by duodenobiliary reflux and cholangitis (1).

 There is also known a method of restoring the passage of bile into the intestine by forming hepaticoyunoanastomosis. Hepaticojejunostomy can exclude reflux, but it does not completely prevent infection of the biliary tract and does not create optimal digestion conditions in the duodenum (2).

 Various types of known termolateral anastomoses (according to Kocher-Mamman) (3) are devoid of many disadvantages of supraduodenal choledochoduodenoanastomoses: there is no residual cavity with microlites and putty, there is no deformation of the duodenum and a prolonged stasis of duodenal contents in the bile ducts. However, this method also has several disadvantages, which include creating conditions for reflux of the duodenal contents into the bile ducts with the occurrence of prerequisites for the development of cholangitis (4).

 Closest to the proposed method is a method of restoring the continuity of the common bile duct with its extensive defects by mobilization of the duodenum (5).

 This option has a number of disadvantages: it is not able to eliminate defects more than 2 cm, permanent duodenostasis develops due to the tension of the duodenum, dyspeptic symptoms, the function of the large papilla of the duodenum, impaired anastomosis failure rate up to 8-10% and the formation of strictures .

 Sometimes situations arise when there are extensive defects of hepatic choledochus (3 cm or more), the closure of which is impossible by the above methods, while it is important to maintain the activity of the sphincter apparatus of the large papilla of the duodenum with its function unchanged. This situation is possible after resection of the common bile duct due to tumors, cicatricial strictures, extensive bedsores of the common bile duct in Mirizi syndrome and cicatricial strictures of the common hepatic and common bile ducts.

 This problem is solved by the method of mobilizing the duodenum according to Kocher and mobilizing the head of the pancreas by dissecting its own ligament of the hooked process and moving the pancreas head to the gate of the liver and applying an end-to-end anastomosis followed by drainage to restore hepatic choledochus continuity, improving the results of the treatment of extrahepatic bile duct diseases requiring extensive resections of hepatic choledoch due to the prevention of duodenostasis, maintaining the function of the large papilla of the duodenum and reducing the incidence of hepatic choledochoanastomosis failure.

 In practice, the method is as follows.

 Surgical access - upper median laparotomy. Perform cholecystectomy, revision of hepatic choledochus and resection of its pathologically altered area. They mobilize the duodenum according to Kocher. Next, the portal and part of the superior mesenteric veins are isolated, which allows you to expose and dissect your own ligament of the hook-shaped process of the pancreatic head. After dissection of the own ligament of the hook process, the head of the pancreas becomes mobile and can be freely moved to the gate of the liver. Mobilization of the duodenojejunal transition provides an even greater opportunity for moving the head of the pancreas. After crossing the above ligaments, the pancreas head is transposed to the gate of the liver, thus ensuring the convergence of the edges of the stumps of the common hepatic and common bile ducts. To prevent insolvency of hepatic choledochoanastomosis, hepatic choledochus is drained through the left hepatic duct with drainage through the round ligament of the liver. End-to-end hepatic choledochoanastomosis is carried out by a continuous precision suture without trapping the mucous membrane with an atraumatic needle with a 5/0 absorbable suture. In the postoperative period, solutions of antibacterial drugs are introduced into the bile ducts through the drainage, depending on the sensitivity of microflora to them. Drainage is removed 3 weeks after surgery.

 Previously, the technique was developed on the corpses of people aged 30 to 76 years.

Example: Patient K. (and / b 26067) was admitted to the Moscow City Clinical Hospital 67 March 2, 2001 with complaints of pain in the right hypochondrium, fever up to 38 ^o C, nausea and vomiting, yellowness of the skin and sclera, dark urine. Similar attacks began a year ago, at the same time with ultrasound revealed cholelithiasis. Attacks with fever and chills notes for 3 months. Over the past 5 months, she lost 15 kg. Upon receipt, a moderate condition. Pulse 80 beats per 1 minute, blood pressure 140/90 mm Hg Objective examination data were typical for inflammation of the gallbladder and extrahepatic bile ducts. Blood tests noted hyperbilirubinemia and signs of cytolysis (increased ALT and ACT) with increased alkaline phosphatase. An increase in urea indicated a negative nitrogen balance. Ultrasound revealed pneumobilia in the unexpanded intrahepatic bile ducts. Gall bladder with fuzzy contours, contains calculi. The common bile duct is unevenly expanded to 18 mm; its lumen contains inhomogeneous contents in the form of a suspension and bright echoes up to 17 mm. It is impossible to exclude the message between the extrahepatic bile ducts and the duodenum 12. With esophagogastroduodenoscopy in the antrum of the stomach 4 cm from the pylorus, the portion of the wall of the stomach with convergence of folds and the flow of bile from an opening up to 2 cm in size is visible along the lesser curvature. The endoscope is freely held through the opening, presumably into the cavity of the gallbladder. The presence of cholecysto-gastric fistula has been established. With a panoramic x-ray, there are no signs of aerobilia, and when the stomach is contrasted, barium suspension enters the gallbladder.

 Against the background of conservative measures, the inflammatory process quickly regressed. By the next day the pain disappeared, the temperature returned to normal and the patient was transferred to a meal through her mouth. Blood bilirubin normalized within 5 days, aspartic and alanine transaminases within 2 weeks. ESR indicators - after 3 weeks. On the 4th day after admission, enteral probe nutrition was connected with a balanced nutrient mixture in connection with a deficiency of trophic status of moderate severity.

 Clinical diagnosis: cholelithiasis, acute calculous cholecystitis, choledocholithiasis, obstructive jaundice, cholangitis, Mirizi-2 syndrome (vesiculate bile duct fistula). Cholecystogastric fistula.

 Concomitant diseases: coronary heart disease, diffuse cardiosclerosis without circulatory failure, hypertension of the II degree, chronic bronchitis, type II diabetes mellitus, moderate trophic deficiency.

 One month after admission, the patient underwent surgery from the upper middle access. Produced dissociation of the cholecystogastric fistula with a diameter of up to 2 cm with its excision and gastroplasty. With cholecystectomy in the area of the destroyed cystic duct, a fistula was diagnosed between the gallbladder and the anterior wall of hepaticoholedoch. Fistula is fragmented. A defect in the hepatic choledoch is 1.2 • 1.5 cm in size, through which the calculus is visible. The width of the common bile duct at the site of the defined duct is not less than 2.5 cm. A hepatic choledochotomy of 2 cm was made through the fistula with removal of a calculus 2.5 * 3.2 cm in size. During the audit of extrahepatic bile ducts, it was established that the hepatic duct itself was 1.5 cm from the confluence of the right and left ducts and the pancreatic part of the common bile duct are thick-walled, but not widened (7-8 mm). Hepatic choledoch at the site of the extracted calculus is a wound granulating surface with destructive and cicatricial changes.

 In connection with the threat of the development of cicatricial stricture of hepatic choledochus in the postoperative period, it was decided to resect the altered part of the duct. As a result of resection of the duct, a defect of 5 cm was formed. The pancreas without signs of chronic inflammation. In the absence of expansion of the distal part of the common bile duct, bougie 2 freely passed through the papilla, which was an indirect sign of the preservation of the functional activity of the sphincter apparatus of the large papilla of the duodenum. It was not possible to staple end-to-end hepatic and common bile duct stumps after mobilization of the duodenum due to a large defect between the ends of the ducts. The portal and superior mesenteric veins were extracted, leaving the inferior vein of the hooked process, then their own ligament of the hooked process of the pancreatic head was crossed and the duodenojejunal junction was distinguished. The pancreas head has become mobile and freely moved to the gate of the liver. The lumen of the common hepatic duct (7-8 mm) did not match the diameter of the stump of the common bile duct. For congruence of the anastomosis, an extension of the incision of the common hepatic duct to the left hepatic was performed. At the same time, a lumen of 1.5 cm was formed. Decompression drainage of the left hepatic duct through the round ligament of the liver was performed. Stitching of the hepatic and common bile ducts is performed by a continuous precision suture without being trapped by a polysorb 5/0 mucous thread with an atraumatic needle. Drainage of the subhepatic space through an incision in the right lumbar region. The duration of the operation is 7 hours, blood loss was 1500 ml. The patient is extubated on the operating table.

 On the 10th day after the operation, fistulocholangiography was performed through a drainage installed transumbilical to the left hepatic duct. Unexpanded intrahepatic bile ducts are contrasted. Hepatic choledochus is short, homogeneous, with a diameter of 12 mm. The intake of contrast medium in the duodenum 12 is good, portioned. Drainage from the bile ducts was removed on the 25th day after the operation.

 In the postoperative period, a nonspecific complication was noted in the form of an intra-abdominal abscess located in the right mesogastrium, which was drained by a puncture method using double-lumen drainage under ultrasound control. The patient was discharged in satisfactory condition after removal of all drains 77 days after admission and 58 days after surgery.

 1 year after the operation, the patient does not complain, notes an improvement in the quality of life. Laboratory indicators are normal. With ultrasound, the intrahepatic ducts are not dilated. The common hepatic duct 1.5 cm long, 7.5 mm in diameter, is connected at an angle to a short (1.5 cm) choledochus with a diameter of 6.9 mm. No calculi were found in hepaticoholedoch. The head of the pancreas is visualized at the gate of the liver. The pancreas is medium in size with signs of fibrosis, the Wirsung duct is not enlarged.

 The proposed method for restoring the continuity of hepatic choledoch after its extensive resections contributes to the physiological passage of bile into the duodenum with preservation of the normal function of the sphincter of Oddi, the prevention of duodenostasis and can be used for diseases of the extrahepatic bile ducts associated with impaired hepaticocholedoch patency (Mirizi syndrome, damage, strica, benign and malignant tumors) with preserved function of the large papilla of the duodenum.

List of references
1. Nekhaev I.A. Improving the methodology for the formation of biliodigestive anastomoses. - Abstract of Ph.D. - Moscow. - 1980. - 20 p.

 2. Halperin E.I. Dederer Yu.M. Non-standard situations during operations on the liver and biliary tract. - M. - Medicine. - 1987. - 334 p.

 3. Mamanna C.Z. Comment eviter le eviter le reflux dans les anastomoses biliodegistive. - Journal of Chirurgie, 1955, 7, p. 310-335.

 4. Nemishev A. A., Delonsky B.V. Surgery of the liver and bile ducts. - Kiev. - 1975.

 5. Teremov S. A. Terminolateral anastomoses as a method of ending choledochotomy. - Annals of surgical hepatology. - 1998. - T.3. - 1. - S. 80-83.

Claims (1)

A method for restoring the continuity of the bile ducts after extensive resection of hepatic choledochus, including mobilization of the duodenum and the application of end-to-end hepatic choledochoanastomosis followed by drainage of the hepatic choledocho through the left hepatic duct and the round ligament of the liver, characterized in that the head of the pancreas is moved through the pancreas ligaments of the hook process and mobilization of the duodenojejunal transition.