RU2261058C2 - Method for creating hepaticojejunal anastomosis after rou having subparietally peritoneally fixed unlocked loop with x-ray-positive label - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves fixing bowel segment defunctioned after Rou on pars nuda at an acute angle to bile ducts along a circle of 2.0-2.5 cm to parietal peritoneum. Ring-shaped titanium clip label sutured to intestine and cut on one side is left between parietal peritoneal and serous tunic of intestine.

EFFECT: facilitated search of anastomosis intestine in postoperative period.

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Description

The invention relates to medicine, namely to surgery.

In reconstructive surgery of the biliary tract, the anastomosis of the ducts with a long loop of the jejunum disconnected along the Roux is currently recognized and priority on the grounds that in this case an anastomosis of sufficient width without tension of the seams is possible, stasis of bile and reflux of intestinal contents are excluded, it is possible to use controlled drainage and reducing the risk of complications such as failure of joints. Severini A., Cozzi G., Salvetti M., Mazzaferro V., Doci R. (Management of complications from hepatobiliary surgery using the percutaneous transjejunal approach. Tumori 1997 Nov-Dec: 83 (6): 912-917), prefer hepatikoejunostom also because in the event of complications, transdermal, transjeunal use of stents, dilatation, litholysis is possible.

Castaing D. et al. (Castaing D., Azoulay D., Bismuth H. Percutaneous catheterization of the intestinal loop of hepatico-jejunostomy: a new possibility in the treatment of complex biliary diseases. Gastroenterol Clin Biol, 1999 Aug-Sep; 23 (8-9): 882-6) report on the high efficiency of transdermal transeyunal catheterization of the intestinal loop of the hepaticoyunoanastomosis in the diagnosis and treatment of obstructive jaundice. 155 diagnostic and treatment procedures were performed in 53 patients over 10 years (stricture dilatation, calculus extraction, stenting, biopsy). Complications were observed in 15% (cholangitis), there were no fatal outcomes. The authors believe that this type of treatment is an alternative to repeated "open" surgery on the bile ducts.

Bressani Doldi S. et al. (Bressani Doldi S., Marinoni M., Lattuada E., Micheletto G., Zappa MA Complete section of the main bile duct during laparoscopic cholecystectomy. Surgical treatment. Minerva Chir, 2000 May; 55 (5): 377-81) recommend form an anastomosis according to Ru with a blind subcutaneous jejunal loop, while a transanastomotic stent was not used. Lillemoe K.D. et al. (Lillemoe KD, Petrofski JA, Choti MA, Venbrux AC, Cameron JL Isolated right segmental hepatic duct injury: a diagnostic and therapeutic challenge. J. Gastrointest Surg 2000 Mar-Apr; 4 (2): 168-77) on the contrary, recommend a period of 8 months to install this kind of stents. In cases where scarring of the hepatikojunoanastomosis Ruiz J, Torres R. (Ruiz J, Torres R. Translaparoscopic jejunal approach for benign stricture of Roux-en-Y hepaticojejunostomy. Surgical Endoscopy 2001 May; 15 (5): 518) offers transjunal dilation under laparoscopy control (1 clinical observation), a Baron T.N. (Baron, T.N., Establishing a systematic endoscopic approach to the management of anastomotic biliary strictures is needed. Liver Transpl 2001 Apr; 7 (4): 378-379) systematic dilatation.

Hutson D.G. et al. (Hutson DG, Russell E., Levi JU, Jeffers LJ, Reddy KR, Yrizarry JM, Scagnelli T., Sleeman D., Schiff ER, Livingstone AS Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis. World J. Surg 2001 Oct; 25 (10): 1251-3) report the following treatment option for biliary tract strictures (including tumors, primary sclerosing cholangitis). A choledochojejunoanastomosis is formed with the abduction of the intestinal loop in the subcutaneous tissue (Quintero GA, Patino JF (Quintero GA ,, Patino JF Surgical management of benign strictures of the biliary tract. World J. Surg 2001 Oct; 25 ( 10): 1245-50), through which dilation (including repeated) of strictures is further performed, with a fifteen-year survival rate of 64%, and in cases with cholangiocarcinoma or cirrhosis - 30%. Beckingham IJ et al. (Beckingham IJ , Krige JE, Beningfield SJ, Bornman PC, Terblanche J. Subparietal hepaticojejunal access loop for the long-term management of intrahepatic stones. Br.J. Surg, 1998 Oct; 85 (10): 1360-3) used this technique in the treatment of hepatolithiasis (n-21) (repeated x-ray endobiliary interventions (removal of calculi, dilatation of strictures) were performed through a fixed intestinal loop).

Thus, the tendency to “minimally invasive” in the treatment of obstructive jaundice is also actively introduced in reconstructive surgery, while initially creating bilio-jujunostom, the authors try to create conditions such that in the long term with the development of various kinds of complications (anastomotic stricture, recurrent choledocholithiasis, tumor, etc. .) it was possible to correct them with minimal trauma to the patient, since repeated surgical interventions with obstructive jaundice are accompanied by higher mortality and the number of complications neniy.

For the prototype, we chose a method for the formation of choledochojejunoanastomosis with a fixed in the subcutaneous tissue ruin-disconnected intestinal loop through which further (if necessary) dilation of the stricture of the biliary tract (Hutson DG, Russell E., Levi JU, Jeffers LJ, Reddy KR, Yrizarry JM , Scagnelli T., Sleeman D., Schiff ER, Livingstone AS Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis. World J. Surg 2001 Oct; 25 (10): 1251- 3).

The disadvantage of this technique is the “artificial” creation of a “postoperative” hernia in the primary operation, since part of the disconnected intestinal loop of the choledochojejunoanastomosis is intentionally fixed in the subcutaneous tissue to facilitate its search in the development of various kinds of complications in the long term. In addition, an incision of the skin and subcutaneous tissue is necessary to search for a fixed loop.

The technical result of the proposed method consists in the formation of hepaticoyunoanastomosis according to Ru with fixation of the disconnected pars nuda loop at an acute angle to the bile ducts to the parietal peritoneum, while between the last and serous membranes of the intestine is left hemmed with two gray-serous sutures to the intestine (to prevent dislocation) a ring-shaped titanium clip cut on one side, serving as an x-ray positive tag.

The essence of the proposed method consists in the formation of hepaticoyunoanastomosis according to Ru with subparietal-peritoneal fixation of the disconnected loop with an x-ray positive mark is that (Fig. 1) in the segment of the disconnected segment of the small intestine (1) adjacent to pars nuda, along a circle with a diameter of 2 , 0-2.5 cm, several serous sutures are applied (2) for subsequent fixation to the parietal peritoneum in the right hypochondrium (in this case, it is desirable to create an acute angle between the disconnected loop and extrahepatic bile ducts, as this will facilitate in in the longest, transejunal endobiliary interventions, and certain difficulties arise during the formation of an obtuse angle), and a titanium clip curved in the form of a ring is fixed to the intestine from the previously applied sutures with two gray-serous sutures to the intestine (3). At the same time, it is more practical to use a ring cut on one side, rather than a solid one, since it is precisely on its inner diameter that medical diagnostic tools (catheters, guides, etc.) must pass, and the existing cut on the ring will not limit them in diameter , due to the fact that it is easily expandable. After this, the sutures between the intestine and the parietal peritoneum are tied, and the clip that is inside the sealed circle from the sutures of the clip is an x-ray target mark. In the postoperative period, using this label during an X-ray examination, it is possible to easily and accurately detect a fixed disconnected intestinal loop of hepatikojejunoanastomosis and, if necessary, to perform minimally invasive percutaneous transjeunal retrograde interventions on the bile ducts (for example, endobiliary dilatation of hepatojejunoanastomosis). In this case, the risk of infection of the abdominal cavity is virtually eliminated due to the previously imposed series of sealed seams around the mark.

Thus, the formation of hepaticojejunoanastomosis according to the proposed method creates the possibility of quick, safe and unhindered access to the disconnected loop of the jejunum, allows for minimally invasive percutaneous transjeunal retrograde interventions on the bile ducts and eliminates the artificial creation of a “postoperative” hernia.

Clinical example.

Ratnikov N.V., born in 1950, (medical history No. 17) was treated in the surgical department of the 7th city hospital in Ivanovo since 3.1.2003 with a diagnosis of chronic inductive pancreatitis, an extended stricture of the distal bile duct, pancreatic cyst glands, cholecystostomy from October 1, 2002. Concomitant pathology - chronic bronchitis, pneumosclerosis, coronary heart disease, postinfarction cardiosclerosis. Complaints about the constant discharge of bile by cholecystostomy in the amount of 600 ml per day, light stool color during the last three months. Periodically, with errors in the diet, pain in the epigastrium and right hypochondrium, passing after taking antispasmodics. History 1.10.02. operated on an emergency basis for obstructive jaundice due to chronic inductive pancreatitis, the terminal block of the biliary tract. When fistulocholecystocholangiography (presented below) (figure 2) expanded the common hepatic duct and the initial section of the common bile duct to 1.7 cm, an extended stricture of the common bile duct about 3 cm long, blots of contrast are determined in the duodenum.

In leukocyte blood tests, 9.8 g / l, potassium - 4, sodium - 146 mm / l, ACT - 0.24, ALT - 1.04, alkaline phosphatase - 6.5 B. units, coagulogram - decreased fibrinolytic activity ( 8.5%) and heparin tolerance, total protein 66.5 g / l, urea 4.61 mm / l, bilirubin - 10.8 μmol / l. Diastasis of urine - 8 units. ECG - fibrosclerotic changes in the myocardium (post-infarction). When examining the function of external respiration, violations of the ventilation function of the lungs were not detected, bronchial patency was not impaired. With USS - The pancreas is enlarged, in the body and tail, the main pancreatic duct is clearly widened, in the head there is a fluid inclusion of 5-5-6 cm, the contents are not homogeneous, the liver is normal in size, homogeneous. Choledoch 9 mm, the gallbladder is normal in size, the contents are not homogeneous, in the lumen of the tube. Given the presence of an extended stricture of the terminal portion of the common bile duct due to chronic inductive pancreatitis, the practically absence of free passage of bile into the intestine, the presence of a functioning cholecystostomy with a constant discharge of bile at 600 ml per day, surgical treatment is indicated. 01/15/2003 the patient was operated on. Performed laparotomy, cholecystectomy, hepatikoejunostomy on an isolated loop of the jejunum according to Ru with subparietal-peritoneal fixation of the disconnected segment with an x-ray-positive mark, drainage of the abdominal cavity. Operation progress: the old postoperative scar in the right hypochondrium is excised. The abdominal cavity is opened. During the audit: the head and body of the pancreas are dense, enlarged, the head is about 12 cm in diameter, the cyst is not detected. The gall bladder is sclerotized, reduced in size. The total hepatic duct is 1.7 cm in diameter, the common bile duct is in the form of a cord. Cholecystectomy Formed hepatikoyunoanastomosis on a long isolated loop of the jejunum according to Ru. 15 cm away from the hepaticojejunoanastomosis by pars nuda of the disconnected loop to the jejunum, two gray-serous sutures fix a titanium clip (8 mm thick) curved in the form of a ring. Around a clip 2.0 mm in diameter around the clip, 6 seroserotic sutures were placed with their subsequent fixation to the parietal peritoneum in the right hypochondrium (an acute angle was created between the disconnected loop and extrahepatic bile ducts). Drainage in the subhepatic space. Sanitation of the abdominal cavity. Layer wound closure tightly.

On January 17, 2003, an abdominal x-ray was performed, in which in the right hypochondrium an X-ray-positive mark in the form of a target ring on a disconnected loop of the jejunum of the hepatic intestine is clearly visible. Focusing on it, at any time after the operation, it is safe to conduct minimally invasive transdermal transeunal therapeutic and diagnostic measures.

Claims (1)

A method for the formation of hepaticojejunoanastomosis according to Ru, including the application of a biliojunostomy with an intestinal loop disconnected according to Ru, characterized in that the portion of the disconnected loop of the small intestine is fixed pars nuda at an acute angle to the bile ducts in a circle of 2.0-2.5 cm with separate serous sutures to parietal peritoneum, while between the last and serous membranes of the intestine, hemmed sero-serous sutures are left to the intestine, an annular titanium clip cut on one side - an x-ray positive label.

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