RU2229849C2 - Method for preventing complications at applying choledochoduodenoanastomosis - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the present innovation deals with forming choledochoduodenoanastomosis in patients with pathology of bile-excretion system (mechanical jaundice, purulent cholangitis). Anastomosis should be formed with the help of adapting suture, moreover, atraumatic needle with synthetic absorbable ligature of 4/0 diameter, preimpregnated with 10%-xymedon solution, should be punctured into duodenal wall at the distance of about 3.5-4 mm against the edge from the side of serous membrane, then it comes through muscular membrane, submucous foundation to be withdrawn into the lumen, then needle's direction is changed to opposite: needle should be punctured into the site located between serous and muscular duodenal membrane to direct it from inside outwards, then it is punctured out in the site being 1.5-2 mm against duodenal edge, then from inside outwards by leaving 2 mm against the edge one should direct the needle through the whole thickness of common bile duct to withdraw it at its serous membrane. Then needles are crossed and tightened in opposite sides, in postoperative period one should wash the common bile duct and applied biliodigestive anastomosis by introducing 10%-xymedon solution into choledocus through the drainage, in postoperative period xymedon is introduced per 0.4 g four times daily per os that provides hermetic nature of anastomosis. EFFECT: higher efficiency of prophylaxis. 7 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, is intended for the formation of choledochoduodenoanastomosis and can be widely used in surgical treatment of patients with pathology of the biliary system (obstructive jaundice, purulent cholangitis).

The most reliable and affordable option for internal drainage of the duct at the end of operations on the biliary tract is the imposition of choledochoduodenoanastomosis (CDA). A known method of forming CDA according to Jurash (figure 1), which consists in the fact that after opening the common bile duct in the longitudinal direction and the duodenum in the transverse direction at the incision level of the common bile duct, sutures are applied starting from the intestinal wall, piercing the needle through all layers intestines from the outside to the inside and then passing it through the wall of the common bile duct from the inside to the outside [8, 9].

Analogues of our invention are CDA methods according to Jurash [8, 9] and intestinal suture according to Motson (figure 2) [7], which have the following disadvantages:

1. An exact comparison of stitched tissues with serous surfaces is not achieved, since the edges of the duodenal mucosa (duodenum) are turned out.

2. Turning the intestinal mucosa outward violates the biological integrity of the suture and leads to leakage of bile and duodenal contents into the free abdominal cavity, bacterial contamination and enzymatic alteration of tissues, which leads to the development of local peritonitis in the CDA area, healing of the suture line by secondary tension, followed by a high risk of cicatricial strictures of the anastomosis.

3. Injury to the mucosa when trying to screw it in with tweezers and immersion in the suture line at the time of thread tightening leads to necrosis of the edge of the mucosa in the CDA zone, healing of the anastomosis by secondary tension, which subsequently leads to a rapid narrowing of the lumen of the anastomosis and a violation of the bile duct.

4. Interposition of the duodenal mucosa between the serous surfaces of the common bile duct and duodenum disrupts the biological integrity of the suture, since the mucous membrane in this case is squeezed by the thread and necrotic.

5. When suturing according to Motson, only the serous membranes of the connected tissues are well fixed to each other, but there is no adaptation of the mucous membranes of the stitched areas. Therefore, the use of this method for connecting dissimilar tissues (choledochus and duodenum) leads to a lack of biological tightness, healing of the suture line by secondary tension with a high risk of formation of scar stricture.

The closest analogue is CDA according to Jurash [8, 9], which we took as a prototype with the indicated disadvantages.

To ensure the conditions of free outflow of bile and inflammatory exudate, as well as sanitation of the anastomosis zone, a number of clinics perform external drainage followed by washing with various solutions of antiseptics (furatsilin, antibiotics, sulfonamides, etc.). To improve the healing processes, methyluracil is also used locally in the form of a 0.8% solution and inside in the form of tablets of 0.5 g 3 times a day [5]. However, this method has the following disadvantages:

1. With local and internal use does not have antiseptic effects.

2. Does not cause a noticeable intensification of regeneration processes.

3. Does not have a positive therapeutic effect on the secretion of bile, motility of the biliary tract and gastrointestinal tract, the dysfunction of which occurs during surgical interventions in the biliopancreatoduodenal region.

The method of using methyluracil topically and internally was taken by us as a prototype.

When developing a new method, the following tasks were set:

1. When applying CDA, to adapt as much as possible to each other the existing anatomical layers of the walls of the common bile duct and duodenum by combining both mucous membranes and serous membranes in the suture line and to ensure physical integrity of the anastomosis even when one row of sutures is applied.

2. Perform a suture in the least traumatic way, avoiding the conditions for necrosis of the edges of stitched tissues during the application of CDA.

3. To provide during the intervention and in the postoperative period an effective local antiseptic in the anastomotic zone, excluding bacterial contamination and conditions for the development of local peritonitis.

4. To exert a local pharmacological effect on the process of adhesion of the walls of the duodenum and choledochus, which reduces the alteration of stitched tissues, suppresses excessive edematous-exudative processes in the anastomotic zone, activates proliferation, collagenogenesis, stimulates early epithelization and increases the strength and reliability of CDA.

As a tool that can have a similar pharmacological effect, the medicine uses Ximedon, developed by the Institute of Organic and Physical Chemistry. A.E. Arbuzov KSC RAS, Kazan State Medical University [1-4]. Stimulation of wound healing, including the gastrointestinal tract, has been proven experimentally [1, 4, 6]. However, in the literature we have not seen reports of local use of Xymedon during the application of CDA and subsequent local therapy with this drug.

To solve the tasks we have proposed and successfully put into practice a method for applying CDA using a precision adaptive suture and Xymedon.

The purpose of the invention is the prevention of complications during surgery choledochoduodenostomy.

The goal is achieved in that the anastomosis is formed using a precision adaptive suture, while an atraumatic needle with a synthetic absorbable thread 4/0 in diameter, previously impregnated with a 10% solution of xymedon, is injected into the wall of the duodenum at a distance of 3.5-4 mm from the edge from the side of the serous sheath, is carried out through the muscular membrane, submucosal base, mucous membrane and is discharged into the intestinal lumen, then the direction of the needle is reversed, the needle is punctured at a point located between the serous and muscle membrane KDP is carried out from the inside out and punctured at a point at a distance of 1.5-2 mm from the edge of the intestine, then from the inside outward, departing from the edge by 2 mm, the needle with the thread is drawn through the entire thickness of the common bile duct and displayed on its serous membrane, then the threads cross each other and stretch in opposite directions, while the section of the duodenal mucosa, turned outwards, is tucked in without falling into the line of the anastomosis, and the mucous and serous membranes of the intestine and common bile duct are precisely and reliably matched to each other, ensuring In the postoperative period, the common bile duct and superimposed biliodigestive anastomosis are washed by introducing a 10% solution of xymedon into the choledoch through drainage; in the postoperative period, per os is injected with xymedon 0.5 g 4 times a day. The additional passage of the thread through the serous membrane of the intestine from the inside outward, closer to the edge and departing from the first injection inside the gut without capturing other layers, allows you to immerse the inverted mucous membrane inside the lumen of the anastomosis and thereby precisely match the stitched organs with serous surfaces to create the biological integrity of the anastomosis . An additionally performed technique, including secondary capture of only the serous membrane of the intestine, provides a hemostatic effect, since the portion of the mucous membrane captured in such a suture from the edge, while tightening the suture, is pressed against the muscular-submucous layer and serous membrane, providing reliable hemostasis. Stitching of the intestine through all layers, first from the outside to the inside, and then additional stitching of only the serous membrane from the inside to the outside allows the serous membrane to be pulled inward, to move it even more inward, and thus precisely compare the serous cover of the intestine and the common bile duct, which is much inferior in intestinal thickness the wall.

An example of the method (in figure 3 graphic material shows a General view of the formation of choledochoduodenoanastomosis).

The proposed method is as follows. An atraumatic needle with a thread 1 is injected into the intestinal wall at point A at a distance of 3.5-4 mm from the edge from the side of the serous membrane 2, passed through the serous membrane, muscle membrane, submucosa and mucous membrane 3 and removed at point B (Fig. 3-5). Then the direction of the needle is changed in the opposite direction. The needle is pierced at point B, located between the serous and muscle membranes of the intestine, carried out from the inside out and punctured at point G at a distance of 1.5-2 mm from the edge of the intestine (Fig.3-5). Further, from the inside outward, backing away from the edge by 2 mm, a needle with a thread is drawn through the entire wall thickness of the common bile duct 4 and is removed on its serous membrane at point D (Fig. 3). After that, the ends of the thread 1 cross each other and pull in opposite directions (figure 5). At the same time, the portion of the mucous membrane 5 turned outward (Fig. 4) is refueled inward (Fig. 5) and does not fall into the line of the anastomosis. In this case, the serous membranes of the common bile duct 4 and gut 2 are combined (Fig. 5), and when tightening the threads, both the serous and mucous membranes of the common bile duct and gut are firmly and accurately compared (Fig. 6). This ensures complete tightness of the anastomosis: Fig.7 shows the seam area after fully tightening the ligature.

To assess the effectiveness of the proposed method, we took the following indicators:

1. The general condition of patients.

2. Clinical (leukocyte formula, leukocyte intoxication index) and biochemical (bilirubin, transaminases, ferritin test) blood tests.

3. The rate of bile drainage of the common bile duct.

4. The quantity and nature of the exudate by trapping drainage to the anastomosis zone.

5. Data of abdominal ultrasound, cholangiography, etc.

6. Long-term results.

The proposed method has been successfully implemented in surgical practice in hospitals No. 12 and 35 of Nizhny Novgorod. From 1990 to 2001 under our supervision in the surgical department of hospital No. 35 there were 370 patients with obstructive jaundice syndrome of various etiologies. The most severe of these were elderly and senile patients (269 patients). Of the 189 patients operated on in one stage, 75 completed the operation on the bile ducts by applying a biliodigestive anastomosis (40%). In a number of patients, we applied the method described above by us. We applied anastomosis on the inflamed bile ducts, that is, in conditions where the highest accuracy of tissue connection and tightness of the anastomosis are required. Moreover, all patients treated with this method were over 60 years old, had several concomitant diseases and were at high risk. The method is used in surgical treatment of elderly and obese patients with obstructive jaundice and purulent cholangitis, the causes of which were prolonged stenosis of the terminal part of the common bile duct, multiple choledocholithiasis, and pancreatic head cancer. We carried out a comparative analysis of the results of treatment of two groups of patients. In the main group, we included patients who had choledochoduodenoanastomosis using a precision adaptive suture and xymedon. The control group consisted of patients who underwent choledochoduodenostomy in the traditional way. All patients received complex therapy according to the standards of medical care. The dynamics of the main indicators of the postoperative period was studied by us using the methods of variation statistics and student criterion. In two groups of patients there were no significant differences in gender, age, bilirubin levels, duration of jaundice and its etiology. At the same time, we found that the patients of the main and control groups during the postoperative period had a number of significant differences.

In the patients of the main group, the general condition remained severe for 2 days, and in the control group for 3.5 days (p <0.01), while the duration of the stay of patients of the main group in the intensive care unit was 32 hours shorter. In the first group, the condition of the patients was assessed as satisfactory reliably earlier - on the 3rd day of the postoperative period, and in the second - only after 7.25 days (p <0.01).

In patients of the main group, the function of the gastrointestinal tract was restored faster. In earlier periods, the appearance of peristalsis was observed (a day earlier, p> 0.05) and the absence of stagnant discharge by the nasogastric tube (from the first day, in the control after 2.25 days, p <0.01). Complete restoration of peristalsis and gas discharge were observed significantly earlier - on the 2nd day of the postoperative period (in the control - after 3.5 days, p <0.001). This allowed the enteral nutrition of patients of the main group to start almost 2 days earlier (p <0.001). In patients operated using our method, there was no impurity of bile in the discharge from the abdominal cavity, leaving the trapping drainage, which proves the tightness of the applied anastomosis (p <0.001). Before and more fully, the activation of patients and the normalization of clinical and biochemical analyzes took place.

Example. Patient B., 70 years old, was admitted to the surgical department of hospital No. 35 of Nizhny Novgorod 07/15/2001 in serious condition. Diagnosis: Acute obstructive phlegmonous calculous cholecystitis, multiple stones of the common bile duct, prolonged stenosis of the terminal part of the common bile duct, purulent cholangitis, obstructive jaundice. Bile flora: in titers of 10 ⁵ CFU / ml Pseudomonas aeruginosa and Enterobacter agglomerans, resistant to semisynthetic penicillins, 3rd generation cephalosporins, aminoglycosides and fluoroquinolones. The operation was performed: cholecystectomy, choledocholithotomy, choledochoduodenostomy using a precision adaptive suture and xymedon. There is no discharge by trapping drainage from the anastomosis zone, the drainage is removed 1 day after the intervention. The leukocyte intoxication index of 11.5 before surgery, a day after surgery 5.75, on the second day of the postoperative period - the norm. The postoperative period is smooth, was discharged on the 12th day in a satisfactory condition.

All our patients were discharged home in satisfactory condition. There were no complications.

Sources of information

1. The effect of xymedon on the healing of wounds of the digestive tract. / Davletshin A.Kh., Izmailov S.G., Kedrin M.Yu. et al. // Act. questions diagnosis and treatment. - Kazan. - 1997. - P.36.

2. Experience with the use of the domestic drug Xymedon in surgery. / Izmailov G.A., Reznik B.C., Izmailov S.G. et al. // Act. issues of diagnosis and treatment. - Kazan. - 1998. - p. 58.

3. Preclinical study of xymedon. / Izmailov S.G., Gorbunov S.M., Izmailov G.A. // Antibiotics and chemotherapy. - 1999. - No. 8. - 12-17 p.

4. Xymedon in clinical practice. / S.G. Ismayilov, G.A. Izmaylov, M.Yu. Averyanov, V.S. Reznik. - N. Novgorod: Publishing House of the NGMA, 2001, 188 p.

5. Kamilov F.Kh., Lazareva D.N., Plechev V.V. Pyrimidines and their use in medicine. // Ufa: Bashk. state honey. Institute, 1992, 158 pp.

6. Kedrin M.Yu. Methods of improving the treatment of damage to the duodenum: Abstract. dis .... cand. honey. Sciences: 14.00.27 / Kazan. state honey. University, Military. honey. Inst. Feder. border. service at Nizhegor. state honey. Acad. - Kazan, 1999, 20 p.

7. Korepanov V.I., Stepanyan S.Kh., Pogosyan S.Sh. New types of intestinal suture (Review of foreign literature). //Surgery. - 1991. - No. 9. - S.167-172.

8. Kochnev O.S. Emergency gastrointestinal surgery. - Publishing house of Kazan. state University, 1984, p.200-201.

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Claims (1)

A method for the prevention of complications when applying choledochoduodenoanastomosis by joining choledochus and duodenum by suturing, characterized in that the suture is preliminarily treated with a solution of xymedon for 30 minutes, and the common bile duct is washed with a solution of xymedon, an atraumatic needle with a synthetic absorbable thread with a diameter of 4/0 the wall of the duodenum at a distance of 3.5-4 mm from the edge from the side of the serous membrane, is passed through the muscle membrane, submucosa, mucous membrane cu and lead into the lumen of the intestine, then the direction of the needle is reversed, the needle is punctured at a point located between the serous and muscle membranes of the duodenum, carried out from the inside out and punctured at a point 1.5-2 mm from the edge of the intestine, then from the inside out , departing from the edge by 2 mm, the needle with the thread is passed through the entire thickness of the common bile duct and excreted on its serous membrane, then the threads cross each other and pull in opposite directions, in the postoperative period the common bile duct is washed and biliodigestive anastomosis with a solution of Ximedon through the drainage and per os injected Ximedon 0.5 g four times a day.

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