RU2254816C2 - Method for pancreatogastroanastomosis at pylorus-keeping pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine, oncology, surgery.

SUBSTANCE: one should perform pylorus-keeping pancreatoduodenal resection, form pancreatic stump, suture the stump into posterior gastric wall, moreover, Wirsung's duct should be catheterized with perforated polyvinyl chloride drainage. The latter should be fixed to the duct's wall. The stump should be sutured in corners with ligatures-"holders" being useful to apply the stump through incision in posterior gastric wall in the center of earlier applied purse-string suture. The stump should be sutured with the edges of incision of posterior gastric wall through cross-sectional incision of anterior gastric wall. One should tighten purse-string suture around the stump, suture in anterior gastric wall. The innovation enables to decrease the risk for complications in the course of operation conducted.

EFFECT: higher efficiency.

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Description

The invention 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 Vater's nipple and terminal part of the common bile duct, chronic pain pseudotumor pancreatitis when performing a radical surgical intervention - the gatekeeper-preserving pancreatoduodenal resection.

Currently, due to the successes in 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 allowed to significantly reduce postoperative mortality during this intervention, but pancreatodigestive anastomosis continues to be the “cornerstone” of pancreatoduodenal resection (1, 2, 3, 4), the largest percentage of which is insufficiency postoperative complications. The complexity of the solution to this problem is evidenced by the large number of proposed methods of pancreatojejunostomy, none of which is absolutely reliable [1].

In recent years, they again turned to the method of pancreatogastrostomy, which was proposed back in the days of A.Whipple [2]. Later it was developed in an experiment on dogs by a domestic surgeon P.V. Kravchenko from the clinic of E.L. Berezov. Based on the experiment, it was concluded that it was not practical [2]. However, in 1999 G. Mason cited summary statistics of 45 authors about 813 PDR with pancreatogastrostomy [4]. Postoperative pancreatitis developed in 2% of patients, pancreatic fistula due to insufficiency of pancreatogastric anastomosis in 4%. Postoperative mortality was only 4%.

The advantages of pancreatogastric anastomosis include ease of implementation, which reduces the time of surgery [3, 4, 5]. The contact of a gland slice with acidic gastric contents prevents the activation of pancreatic enzymes. The absence of factors provoking the development of insufficiency of pancreatodigestive anastomosis allows it to be used with unchanged parenchyma of the gland and narrow pancreatic duct.

The disadvantages of pancreatogastric anastomosis include the possibility of bleeding from a slice of the pancreas into the lumen of the stomach, as well as the capture of a pancreatic duct during suturing of a slice of the gland into the lumen of the stomach [3].

Thus, the development of a method of pancreatogastrostomy, which reduces the risk of bleeding into the lumen of the stomach and eliminates the risk of entrainment of the pancreatic duct in the suture, is relevant.

The closest in the set of essential features to the proposed method is the method of pancreatogastroanastomosis with PDD, given in the work of V.A. Kubyshkin et al., 2001 [3], which is selected by the authors as a prototype.

The known method is as follows: on the cult of the pancreas, a case is formed from the wall of the stomach by fixing the gland to the wall of the stomach. After this, the lumen of the stomach is opened and the stump of the pancreas is sewn with a continuous suture to the wall of the stomach, while controlling that the pancreatic duct does not enter the suture. Then the formation of the case is completed by hemming the capsule of the gland to the wall of the stomach with interrupted sutures.

The known method allows to perform pancreatogastric anastomosis in case of PDD, however, after such an operation, the risk of bleeding in the lumen of the stomach remains, since there is no way to “monitor” the pancreatogastric anastomosis zone after it is completed, which does not exclude the risk of bleeding from the suture zone. There is no complete certainty that the pancreatic duct is not taken into the suture. So Kubyshkin V.A. et al. [3] report the results of pancreatogastroanastomosis in 12 patients. At the same time, 2 patients showed bleeding into the lumen of the stomach from the pancreatogastric anastomosis zone, which was stopped endoscopically. 1 patient died of acute cardiovascular failure.

The aim of the invention is to reduce the likelihood of complications (bleeding from the pancreatogastric anastomosis zone, suturing of the lumen of the pancreatic duct) during pancreatoduodenal resection.

This goal is achieved by the proposed method, including: a transverse incision of the anterior wall of the stomach in the projection of the alleged pancreatogastric anastomosis; the imposition of a purse string suture on the posterior wall of the stomach at the site of the alleged anastomosis in diameter is slightly larger than the cut of the pancreas; holding a pancreatic stump with a catheterized wirsung duct into the lumen of the stomach behind the stitches of the “holder” through the incision of the posterior wall of the stomach in the center of the purse string suture, stitching the stump of the pancreas with the edges of the incision of the posterior wall of the stomach with a nodal suture is made through the incision of the anterior wall of the stomach, then the purse string suture is tied around pancreatic stumps on the posterior wall of the stomach and after controlling hemostasis in the area of pancreatogastric anastomosis from the side of the stomach lumen, the incision of the anterior wall is sutured ka conventional double-row suture.

A distinctive feature is that the Wirsung duct is catheterized by polyvinyl chloride drainage, the stump of the pancreas is carried out into the lumen of the stomach through the incision of its posterior wall in the center of the purse string suture, which are fed through the incision of the anterior wall of the stomach in the projection of the formed anastomosis, and stitching pancreatic stumps with the wall of the stomach are produced from the side of its lumen. After this, the purse string suture on the posterior wall of the stomach around the pancreatic stump is tightened.

The incision of the anterior wall of the stomach allows for constant visual control of the area of the formed anastomosis and to conduct better hemostasis. Catheterization of the Wirsung duct helps to prevent flashing during anastomosis. A purse string suture on the back of the stomach, tied around the stump of the pancreas, also increases the reliability of hemostasis.

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 pancreatoduodenal resection with preservation of the pylorus (according to one of the generally accepted methods), they begin the reconstructive stage of the operation.

The Wirsung duct is catheterized, for which use perforated polyvinyl chloride drainage corresponding to the diameter of the duct. Drainage is fixed to the wall of the Wirsung duct with an atraumatic absorbable thread. After hemostasis, the pancreatic stump is stitched with 8-shaped interrupted sutures at the corners with two stitches, which are subsequently used to hold the stump into the lumen of the stomach. A transverse incision is made up to 6-7 cm in length of the anterior wall of the stomach in the projection of the putative pancreatogastric anastomosis (usually 8-10 cm above the pylorus). A purse string suture is placed on the posterior wall of the stomach at the site of the alleged anastomosis with a diameter slightly larger than a pancreas section. In the center of the purse string suture, an incision is made in the posterior wall of the stomach, corresponding to a cut of the pancreas. With the help of two surgical clamps inserted into the lumen of the stomach through an incision in its anterior wall, the “holder” strings are applied, applied to the corners of the pancreatic stump, which are fed through the incision of the posterior wall of the stomach by the surgeon’s assistant. They carry out a pancreatic stump with a catheterized Wirsung duct through an incision in the center of the purse string suture into the lumen of the stomach 0.5 cm above the mucosa of the posterior wall of the stomach. The stump of the pancreas is stitched with the edges of the incision of the posterior wall of the stomach with a nodal suture, then the previously applied purse string suture around the pancreatic stump on the posterior wall of the stomach is tightened. After controlling hemostasis in the area of pancreatogastric anastomosis from the side of the lumen of the stomach, the incision of the anterior wall of the stomach is sutured with a conventional 2-row suture.

The proposed method is illustrated in FIGS. 1-4, where in FIG. 1:

1 - pancreatic stump;

2 - a spleen;

3 - drainage in the Wirsung duct;

4 - “holder” threads stitched over the edges of the gland in figure 2:

1 - a section in the center of a purse string suture on the posterior wall of the stomach;

2 - the gatekeeper

in FIG. 3 - the pancreatic stump is carried into the stomach and stitched

with its back wall:

1 - section stump of the pancreas;

2 - drainage in the Wirsung duct;

3 - section of the anterior wall of the stomach;

4 - holder threads;

5 - the gatekeeper

in FIG. 4 is a diagram of a completed pyloric preserving pancreatoduodenal resection:

1 - pancreatic stump;

2 - a seam of the anterior wall of the stomach;

3 - duodenojejunostomy;

4 - hepaticoyunoanastomosis.

The proposed method was developed on 10 corpses, then tested in an experiment on 8 outbred dogs. The clinic used 9 patients: three with pancreatic head cancer and six had Vater's nipple cancer. Complications associated with pancreatogastric anastomosis were not noted. There were no fatal outcomes.

EXAMPLE No. 1. SPECIFIC EXECUTION OF THE SUGGESTED METHOD

Patient K., 46 years old, case history No. 4871, was admitted to the surgical department of hospital No. 30 on 5.11.99 with a diagnosis of cholelithiasis, obstructive jaundice. November 8, 1999 the operation was performed: pyloric preserving pancreatoduodenal resection (V.V. Ershov).

Upper median laparotomy. During revision, the tumor is 3 × 2 cm in the region of Vater's nipple. The gall bladder is enlarged, tense. The common bile duct is expanded to 1.5 cm. Mobilization of the gastropancreatoduodenal complex is typical, with preservation of the pylorus. Resection on the line of mobilization.

The Wirsung duct is catheterized with perforated PVC drainage corresponding to the diameter of the duct. The drainage is fixed to the wall of the Wirsung duct with an atraumatic absorbable thread. The pancreatic stump is sutured with eight-shaped sutures and stitched in the corners with two threads. An electrocoagulator made a transverse incision up to 6-7 cm in length of the anterior wall of the stomach in the projection of the putative pancreatogastric anastomosis 10 cm above the pylorus. A purse string suture was placed on the posterior wall of the stomach at the site of the alleged anastomosis with a diameter slightly larger than a section of the pancreas.

An electrocoagulator made a section of the posterior wall of the stomach in the center of the purse string suture, corresponding to a cut of the pancreas. With the help of two surgical clamps inserted into the lumen of the stomach through an incision in its anterior wall, filaments of a “holder” were applied, superimposed at the corners of the stump of the pancreas, which were filed through an incision in the posterior wall of the stomach by an assistant surgeon. A pancreatic stump with a catheterized Wirsung duct was made through an incision in the center of the purse string suture into the lumen of the stomach 0.5 cm above the mucosa of the posterior wall of the stomach. Stitching of the pancreatic stump with the edges of the incision of the posterior wall of the stomach with a nodal suture was performed. A previously applied purse string suture around the pancreatic stump on the back of the stomach is tightened. After controlling hemostasis in the area of pancreatogastric anastomosis from the side of the lumen of the stomach, an incision of the anterior wall of the stomach is sutured with a conventional 2-row suture.

In the bed of the duodenum 12 held a loop of jejunum. Duodenojejunostomy end-to-end anastomosis with a double-row interrupted suture 2 cm below the pylorus. Cholecystectomy Hepaticojejunostomy “end to side” according to Shalimov, 25 cm from duodenojejunoanastomosis. A nasojejunal probe is instituted for duodenojejunostomy. Drainage. Suture of the wound.

Histological examination of the drug No. 6764-72 from 11/28/99: moderately differentiated Vater's nipple adenocarcinoma with germination to the muscle layer of the duodenum. Smooth postoperative course. 11/22/99 in satisfactory condition the patient was discharged home.

EXAMPLE No. 2. SPECIFIC EXECUTION OF THE SUGGESTED METHOD

Patient K., 39 years old, case history No. 4271 was admitted to the surgical department of hospital No. 30 on 5.11.2000 with a diagnosis of pancreatic head cancer. Previously, the patient in connection with obstructive jaundice was performed cholecystoduodenostomy. Operation 9/11/2000. Pylorus-preserving pancreatoduodenal resection (V.V. Ershov).

Upper median laparotomy with a continuation of the incision 4 cm below the navel. Postoperative adhesions are divided. During the audit, distant metastases were not detected. The tumor in the area of the pancreatic head is dense tuberous up to 3 cm in diameter.

Mobilization of the pancreatoduodenal complex with the gallbladder. A portion of the duodenum was preserved 2 cm below the pylorus. Resection of the complex along the line of mobilization.

The Wirsung duct is catheterized with perforated PVC drainage corresponding to the diameter of the duct. The drainage is fixed to the wall of the Wirsung duct with an atraumatic absorbable thread. The pancreatic stump is sutured with eight-shaped sutures and stitched in the corners with two stitches. An electrocoagulator made a transverse incision up to 6-7 cm in length of the anterior wall of the stomach in the projection of the putative pancreatogastric anastomosis 8 cm above the pylorus. A purse string suture was placed on the posterior wall of the stomach at the site of the alleged anastomosis with a diameter slightly larger than a section of the pancreas. An electrocoagulator made a section of the posterior wall of the stomach in the center of the purse string suture, corresponding to a cut of the pancreas. With the help of two surgical clamps inserted into the lumen of the stomach through an incision in its anterior wall, filaments of a “holder” were applied, superimposed at the corners of the stump of the pancreas and served through an incision in the posterior wall of the stomach by an assistant surgeon. A pancreatic stump with a catheterized Wirsung duct was made through an incision in the center of the purse string suture into the lumen of the stomach 0.5 cm above the mucosa of the posterior wall of the stomach. Stitching of the pancreatic stump with the edges of the incision of the posterior wall of the stomach with a nodal suture was performed. A previously applied purse string suture around the pancreatic stump on the back of the stomach is tightened. After controlling hemostasis in the area of pancreatogastric anastomosis from the side of the lumen of the stomach, an incision of the anterior wall of the stomach is sutured with a conventional 2-row suture.

In the bed of the duodenum 12 held a loop of jejunum. Duodenojejunostomy end-to-end anastomosis with a double-row interrupted suture 2 cm below the pylorus. Hepaticojejunostomy “end to side” according to Shalimov, 25 cm from duodenojejunoanastomosis. A nasojejunal probe is instituted for duodenojejunostomy. Drainage. Suture of the wound.

Histological examination of the drug No. 5748-56 from 11/28/99: moderately differentiated intraductal adenocarcinoma of the pancreatic head. The postoperative period was complicated by violations of the evacuation function of the stomach for 15 days, which gradually recovered during conservative therapy. The patient was discharged 2.12.2000, in satisfactory condition.

Sources of information

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

2. Kravchenko P.V. In the book: Issues of surgery of the stomach and esophagus, ed. prof. E.L. Berezova, Gorky. 1956. S. 55-87.

3. Prototype: Kubyshkin V. A., V. A. Vishnevsky, M. V. Danilov et al. Evaluation of methods for completing pancreatoduodenal resection. - Surgery. - 2001. - No. 1. - S. 46-50.

4. Mason G.R. Pancreatogastrostomy as reconstruction for pancreatoduodenectomy. Wrdi J Surg 1999; 23; 23: 221-226.

5. Miedema B.W., Sarr M.G., van Heerden J.A. et al. Complications Follov-ing Pancreaticoduodenectomy. Arch. Surg 1992; Aug; 945-950

Claims (1)

The method of pancreatogastroanastomosis in the pyloric-preserving pancreatoduodenal resection, including the formation of a pancreatic stump, suturing of the pancreatic stump into the posterior wall of the stomach, characterized in that the Wirsung duct is catheterized with perforated polyvinyl chloride drainage, which is fixed to the gland with ", for which it is carried out with a catheterized Wirsung duct through an incision in the posterior wall of the stomach to the center not previously applied purse string suture, and stapling of the stump of the gland with the edges of the incision by the posterior wall of the stomach is performed through a transverse section of the anterior wall of the stomach in the projection of the formed anastomosis, after which a purse string suture around the pancreatic stump is tied and the anterior wall of the stomach is sutured with a double-row suture.

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