RU2231303C1 - Method for surgical treating the cyst of pancreatic caput at chronic complicated pancreatitis - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: after endoscopic papillotomy one should resect the anterior cystic wall only, then it should be tamponed with the strand of greater omentum, pancreas should be crossed at isthmus level to finish operation by forming a distal end-loop pancreatojejunoanastomosis and performing temporal separate external draining of cystic cavity and proximal part of the main pancreatic duct that enables to shorten terms of therapy and rehabilitation in patients of the given category due to keeping the passage of pancreatic juice into digestive tract.

EFFECT: higher efficiency of therapy.

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Description

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

The presence of a formed post-necrotic pancreatic cyst is an absolute indication for one or another surgical treatment due to the risk of severe complications (M.V.Danilov, V.D. Fedorov “Pancreatic Surgery”, 1995).

The question of choosing a method for the surgical treatment of pancreatic cysts remains controversial. Of the variety of proposed options for modern minimally invasive and traditional surgical interventions, 3 groups can be distinguished (C.F. Bagnenko, A.A. Kurygin “Chronic pancreatitis”, 2000):

1) external drainage of the cyst, including under ultrasound control;

2) internal drainage of the cyst - cystodigestive anastomoses (cystogastro-, cystoyo-, cystoduodeno-, including endoscopic and under ultrasound control);

3) radical removal of the cyst (cystectomy, resection of the pancreas of various sizes).

Surgical tactics are chosen depending on the connection of the main pancreatic duct with the cavity of the cyst. If there is a connection between the cyst cavity and the main pancreatic duct, cystejunostomy on the loop of the small intestine turned off from digestion is considered the operation of choice. In the absence of communication of the main pancreatic duct with the cavity of the cyst, it is considered advisable to perform external drainage of the cyst. In this case, cysts with a diameter of up to 5 cm are drained under ultrasound (US) control (A.A. Shalimov et al. “Pancreatic Surgery”, 1997).

Radical and draining operations are traumatic and are accompanied by a large number of early postoperative complications, which, according to published data, reach 40-80%.

An operation of internal drainage, cystejunostomy, was taken as an analogue (M.V. Danilov, V.D. Fedorov, “Pancreatic Surgery,” 1995). Cystejunostomy is the most universal, affordable and safe way of internal drainage of pancreatic pseudocysts. The application of an anastomosis with a small intestine is appropriate for both large and small cysts located extra - or intrapancreatically. The technique of cystejunostomy varies depending on the size and location of the cyst. As an operative access, a wide median laparotomy is performed with hardware correction of the operative access by Seagal expanders. Pancreatic head cysts are accessed through the gland sac by dissecting the gastrointestinal ligament and carefully releasing the anterior surface of the pancreas. After the exact location of the cyst is established, it is opened with a cut along the axis of the pancreas. Sometimes abundant bleeding is stopped by applying nodal and U-shaped sutures. After emptying the cyst and hemostasis, a cystejunoanastomosis is usually applied with single nodular sutures. When this anastomosis is applied, preference is given to the formation of an anastomosis with a jejunum on a disconnected loop according to Ru, give the formation of an anastomosis with a jejunum on a disconnected loop according to Ru, Brown or A.A.Shalimov.

The width of the lumen of the anastomosis should be the maximum possible diameter, at least 4-5 cm.With a small size of the cysts and their deep occurrence, in some cases it is not possible to impose an anastomosis with a diameter of more than 2-3 cm.Larger wall thickness of the anastomosed cyst makes the functioning of the anastomosis more difficult. In these cases, the only way to reliably ensure the outflow of the contents of the cyst and to prevent rapid obliteration of the anastomosis is its formation on the outward drainage prosthesis.

disadvantages

1. Inadequate drainage effect of cystoyunoanastomosis in the first days of the postoperative period, due to swelling of the anastomosis and dynamic paresis of the gastrointestinal tract.

2. Preservation of outward drains through the lumen of the anastomoses for 1-3 months or more to prevent premature obliteration of the anastomosis.

3. The possibility of insufficiency of the anastomosis with the development of peritonitis, suppuration of the cyst cavity, the progression of the initial pancreatic necrosis in the early postoperative period, and in the later stages - premature narrowing and obliteration of the anastomosis and, as a result, relapse of the disease, as well as acute peptic ulcers of the anastomosis zone, often complicated by bleeding.

An external drainage of the cyst under ultrasound control in combination with endoscopic papillotomy was taken as the second analogue.

An endoscopic papillotomy is performed on the patient (endoscopic abdominal surgery is cited according to A.S. Balalykin, 1996).

In a typical method of endoscopic papillotomy, the papillotome is freely inserted into the mouth of the large duodenal papilla and set immediately or after several dissections in the direction of the mouth of the bile duct. Introduction, the correct installation (at 10-11 o'clock of the dial) of the papillotome and to a sufficient depth is the basis of a successful operation. It is facilitated and significantly accelerated if a modern technique for changing catheters is used with endoscopic retrograde pancreatocholangiography on a papillotome along a conductor. If the position of the papillotome is doubtful during the control introduction of the contrast medium and according to the radiopaque marks, it is impossible to dissect the BDS, and with the help of technical methods (pulling up, changing the position of the endoscope, the exit angle of the papillotome, the configuration of its distal section), one should choose the correct direction of administration. When it is reached, the roof is cut. The electrode is pulled slightly so that the roof is raised and part of the electrode is visible. The inclusion of “cutting” and “coagulating” currents of small power produce metered cuts. The completeness of the cut of the ampoule roof is determined visually: in the resulting wound, the walls of the terminal part of the common bile duct should be visible, having a peculiar color and surface character.

Then the patient undergoes external drainage of the cyst under ultrasound control (quoted by V.V. Mitkov “Clinical Guide to Ultrasound Diagnostics”, 1997).

The puncture site is anesthetized with local anesthetics. Despite the use of thin needles, local anesthesia is mandatory, because after this the patient does not respond to a puncture with a needle and skin and peritoneum, lies calmly, which makes it easier and more accurate to achieve a pathological formation of small sizes, and if necessary, repeat punctures. The choice of the path of the needle or drainage is carried out using ultrasound examination and is determined by the shortest distance from the skin to the pseudocysts. After selecting the needle trajectory, the skin is incised with a scalpel, then the anterior abdominal wall is pierced to the peritoneum with a conductor needle. On it, as in the direction, perform the subsequent puncture. When using sensors with a central puncture channel or puncture nozzle, the needle can be advanced vertically or in a slightly oblique direction. The guide line on the monitor screen should cross the punctured formation and fix the intended path of the needle. Thanks to the principle used, the end of even a very thin needle gives a sufficient echo, provided that the axis of the needle coincides with the plane of the cross section of the sensor. When the needle reaches the puncture formation, the stylet is removed and a suction syringe is attached to the needle pavilion. To hold the atraumatic needle within the millimeter width of the image plan, it is desirable to hold the sensor along the longitudinal axis of the body. If this is not possible, the sensor must be placed in a non-standard position so that it is possible to observe a pathological formation and maintain a guide line on the monitor. Under these conditions, a puncture requires holding the breath for patients while advancing the needle. This avoids rupture of the capsule, which can lead to profuse bleeding. After passing the needle 1-2 cm per organ capsule or after reaching a punctured formation, shallow breathing is allowed. If the needle cannot be identified in the tissues, then it is better to remove it, check if it is bent, and repeat the manipulation. Then, a conductor is inserted through the needle, through which the catheters are replaced by the Seldinger method with a larger diameter drainage. If there are a large number of necrotic masses, sequesters or thick contents in the cavity, the diameter of the installed external drainage should be at least 10 Fr. Control fistulography helps determine the shape of the cavity, accurately localize the introduced drainage, and if necessary, adjust its position. After that, the drainage is fixed to the skin.

disadvantages

1. When the cyst is connected with the main pancreatic duct or ducts of the first order, an external pancreatic fistula is formed, which requires closure by surgery.

An operation was adopted as a prototype - duodenum-preserving resection of the pancreatic head (M.V.Danilov, V.D. Fedorov “Pancreatic surgery”, 1995).

Duodenum-saving pancreatic head resection is technically more complex, but more modern surgical intervention, in the treatment of chronic pancreatitis, proposed by N. Beger. The technique of such surgery has its own characteristics.

As an operative access, a wide median laparotomy is performed with hardware correction of the operative access by Sigal retractors, the right corner of the colon is preliminarily separated, KDP is carefully mobilized, they enter the stuffing bag sharply along the line of attachment of the posterior leaf of the greater omentum to the transverse colon, striving avoid damage to the gastrointestinal arteries. The superior mesenteric vein is isolated below and, if possible, above the isthmus of the gland, which is taken on a rubber holder. The stage of the resection of the pancreatic resection 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. A line is cut for the tissue of the head of the gland parallel to the bending of the descending part of the intestine and spaced 5-8 mm from it. The intrapancreatic part of the common bile duct is isolated from pancreatic tissue at its confluence with the main pancreatic duct.

After cutting off the drug, the dorsal duodenopancreatic arterial arch, which, together with other small vessels, provides blood supply to the intestinal wall and the common bile duct, should be preserved. The pancreas remaining on the wall is in the form of an orange peel and usually consists mainly of fibrous tissue.

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 as end-to-end or end-to-side. In the presence of strictures along the duct of the corporocaudal pancreas, the operation is completed by the application of a longitudinal, long pancreatoejunoanastomosis. The duct of the remaining small proximal stump of the gland anastomose with the same loop of the jejunum that was used to anastomose with the distal stump of the gland (according to H. Beger). When stenosing the bile duct, they resort to the application of a biliodigestive anastomosis of the intrapancreatic part of the common bile duct with the same area of the jejunum or the application of a typical supraduodenal choledochoduodeno- or choledochojejunoanastomosis. Next, an inter-intestinal anastomosis is applied.

disadvantages

1. Due to the emerging infiltrate in the bed of the resected head, pressure of the duodenum and intrapancreatic part of the common bile duct occurs with the development of prolonged duodenostasis, gastrostasis and biliostasis.

The objective of the invention is to develop a new method for the surgical treatment of pancreatic head cysts in case of chronic complicated pancreatitis, which is used when the cyst is connected with the main pancreatic duct, eliminating the cyst and not accompanied by biliostasis and duodenostasis.

The essence of the invention lies in the fact that after an endoscopic papillotomy only the anterior wall of the cyst is resected, then it is tamped with a lock of the greater omentum, the pancreas is crossed at the level of the isthmus and the operation is completed by the formation of a distal conceptual pancreatojejunoanastomosis and temporary separate external drainage of the main cystic cavity and the proximal proximal.

The method is as follows

In the preoperative period, the patient undergoes endoscopic papillotomy.

Expanded median access is performed with the intersection of the cartilaginous part of the X-XI ribs at the top and continues 5-6 cm down from the navel, bypassing it to the right. Segal type expanders 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 ° to the frontal plane. To the edges of the wound, in order to avoid drying out during a long operation, wet gauze napkins are hemmed. Next, the organs of the gastropancreatoduodenal zone are mobilized: a large omentum is separated from the transverse colon throughout - from the hepatic angle to the splenic bend. In some cases, the cavity of the lesser omentum is sealed throughout the inflammatory-adhesive process, while the front surface of the pancreas is bluntly and acutely separated from the posterior wall of the stomach. Mobilize the duodenum according to Kocher. This stage is necessary for several reasons: the mobilization performed allows you to palpate the condition of the head, distal choledoch, facilitates further hemostasis and relieves the symptoms of duodenal obstruction if the scar-inflammatory process does not affect the layers of the duodenum. An intraoperative ultrasound study is performed, during which the location of the cyst, the condition of the head and distal portions of the pancreas, common bile duct, and blood vessels are detailed. The front wall of the cyst is resected (Fig. 1, pos. 1), the contents and necrotic tissues are evacuated from the cyst, hemostasis is performed by sewing the bleeding vessels with a monolithic thread on a monolithic needle. They tampon the cyst cavity with a free lock of a large omentum on the vascular “leg” (FIG. 2, pos. 1), drain with a thin double-lumen tube (FIG. 2, pos. 2). The pancreas intersects at the level of the isthmus (figure 1, position 2). Carry out hemostasis along the section line by pinpoint suturing of vessels with a thin monolithic thread on a monolithic needle. We check the patency of the proximal and distal parts of the main pancreatic duct, remove the detected calculi. The proximal section of the main pancreatic duct is drained along the entire length with a thin (3 mm diameter) polyvinyl chloride tube with side holes (Fig. 2, item 3).

Next, the reconstructive stage is performed. On the distal pancreatic stump, a conceptual pancreatojejunoanastomosis is formed (Fig. 2, pos. 4) with a Brown loop disabled (Fig. 2, pos. 3). In the postoperative period, drainage tubes from the cavity of the cyst and from the main pancreatic duct are removed.

The proposed method for the surgical treatment of complicated chronic pancreatitis radically eliminates the cyst of the pancreatic head with the restoration of the passage of pancreatic juice into the digestive tract.

The method was tested on 15 patients for 2 years:

Patient L., 47 years old, was admitted to the clinic on November 20, 2000 with complaints of weight loss - about 10 kg, for girdle pain, aggravated after eating, lack of appetite, nausea. After a set of diagnostic measures (ultrasound, RCP, laboratory tests), the patient revealed a cyst of the pancreatic head, dilatation of the Wirsung duct, and wirsungolithiasis. The patient performed 11/22/2000, percutaneous drainage of the cyst of the pancreatic head under ultrasound control. 11/23/2000 - EPT, RCHP (from the initial section of the Wirsung duct, the contrast is discharged into the cyst cavity, the cyst has a connection with the duct system), biopsy of the BDS.

The patient had an artifact fistula with a separation of up to 300 ml of pancreatic juice per day, the pain was stopped.

During subsequent hospitalization 15/01/01. the patient had fistulography - a discharge of contrast was detected in the main pancreatic duct and further in the duodenum. After the preoperative preparation 24/01/01, the surgical intervention was performed in the amount: “Excision of the anterior wall of the cyst of the pancreatic head. Pancreas intersection at isthmus level. The formation of distal pacreatheunoanastomosis. Tamponization of the cyst cavity with a lock of a large omentum. External drainage of the proximal section of the main pancreatic duct and external drainage of the cyst. Abdominal drainage. ” The postoperative period was uneventful. When control fistulography revealed the closure of the cavity of the cyst. Drainage tubes removed from the site of the former cyst and main pancreatic duct. During hospitalization, the patient received infusion, antisecretory therapy, antibacterial drugs (abactal), prophylaxis of postoperative pancreatitis was carried out, blood components were transfused.

At the follow-up examination after 1 year, the patient does not notice dyspeptic disorders, there is no pain syndrome, she is engaged in physical labor, and gained weight.

During the control ultrasound study: a stump of the pancreas of medium size, increased echogenicity, Virsung duct 2 mm, cystic formations in the pancreas were not detected.

The developed method for the treatment of cysts of the head of the pancreas in case of chronic complicated pancreatitis when using allows to reduce the time of treatment and rehabilitation of this category of patients by 27%.

Claims (1)

A method of surgical treatment of a pancreatic head cyst with chronic complicated pancreatitis, including partial resection of the pancreatic head, characterized in that only the front wall of the cyst is resected after endoscopic papillotomy, then it is plugged with a lock of the greater omentum, the pancreas is intersected at the level of the isthmus and the operation is completed and the operation is completed and the operation is completed conceptual pancreatoeunioanastomosis and temporary separate external drainage of the cyst cavity and proximal stka main pancreatic flow.

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