RU2286728C1 - Method for developing pancreatogastroanstomosis at pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine, pancreatic surgery.

SUBSTANCE: at diameter of the main pancreatic duct being either less or equal to 3 mm after removing pancreatoduodenal complex one should invaginate pancreas into posterior gastric wall at applying sutures. Moreover, it is necessary to fulfill the incision of posterior gastric wall being one third less against pancreatic stump. Stump's invagination should be carried out for the depth of about 3-4 mm. Then one should apply two angular sutures and per two interrupted sutures onto anterior and posterior semicircumference of pancreatic and gastric anastomosis. It is necessary to leave 4 cm against the edge of pancreatic stump. The innovation enables to decrease the risk of anastomosis failure due to sutures' slitting and decrease the trauma of glandular parenchyma.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to pancreatic surgery, and can be used at the reconstructive stage of pancreato-gastroduodenal resection.

A known method of forming pancreatogastroanastomosis on the posterior wall of the stomach with a two-row nodal suture: first, the external suture is applied to the anterior semicircle of the slice of the pancreatic stump and the serous-muscular layer of the hole in the stomach, departing 1.0 cm from the cut line of the pancreas and the cut of the stomach, then the inner a series of sutures between the edge of the pancreatic parenchyma and all layers of the wall of the stomach along its dissection line. Thus, an invagination pancreatogastroanastomosis is formed with a powerful coupling from the wall of the stomach on the gland stump. A description of this technique is given in the monograph by V. A. Kubyshkin and V. A. Vishnevsky “Pancreatic cancer”. Moscow, 2003, p. 240-241.

The disadvantage of this method, in our opinion, is the risk of anastomosis and pancreatic fistula failure due to suture erosion in the soft “juicy” pancreatic parenchyma, intraoperative trauma to the parenchyma of the gland with a large number of sutures with a high risk of local complications of the pancreatic stump.

The objective of the invention is to improve the results of pancreatoduodenal resection by optimizing the method of surgical intervention.

The essence of the proposed method for the formation of pancreatogastroanastomosis at the reconstructive stage of pancreatoduodenal resection is that after standard removal of the pancreatoduodenal complex, the pancreatic stump is invaginated into the posterior wall of the stomach with a minimum number of sutures, and an incision of the posterior wall of the stomach is 1/3 less than the diameter of the stump glands, invaginating the stump of the pancreas to a depth of 3-4 cm, and impose two corner nodal suture and about two nodal seam at the front and rear semicircle anastomosis pancreas and stomach, departing 4 cm from the edge of the residual pancreas.

The application of six single-row sutures dramatically reduces the risk of pancreatogastroanastomosis failure due to minimal trauma to the pancreatic parenchyma with multiple sutures and good blood supply to the anastomosis line. Reducing the length of the cut of the stomach by 1/3 of the diameter of the stump of the pancreas and invagination of the stump of the pancreas into the stomach by 3-4 cm provides a more tight grasp of the stomach of the pancreas in the form of a sleeve.

The method of forming pancreatogastroanastomosis is as follows. After removal of the pancreatoduodenal complex, consisting of the head of the pancreas, duodenum, pyloric antrum, the consistency of the parenchyma of the pancreatic stump and the diameter of the main pancreatic duct are evaluated. With a soft stump parenchyma and a narrow duct (≤3 mm), pancreatogastroanastomosis is formed by a single-row nodal suture at the site of the highest anatomical dilution of the posterior wall of the stomach and pancreatic section. To do this, they additionally mobilize the stump of the gland, separating it from the splenic artery and vein for 3-4 cm. An incision is made in the posterior wall of the stomach 1/3 less than the diameter of the stump of the gland. Impose one nodal suture at the angle of the pancreas and stomach of Fig.1.1, using atraumatic non-absorbable monofilament 4/0. Next, two sutures are applied to the posterior lip of the anastomosis between the pancreas and stomach Fig.1.2. To avoid possible flashing of the main pancreatic duct, the latter is catheterized with a hidden "lost" drainage. Then immerse the pancreatic stump in the stomach to a depth of 3-4 cm and put two nodal sutures on the anterior semicircle of the anastomosis of Fig.2.1. All sutures are superimposed, retreating 4 cm from the intersection line of the pancreatic stump. Achieving sufficient hermeticity of pancreatogastroanastomosis occurs due to the snug fit of the stomach wall to the pancreatic stump (Figure 1 and 2.)

Example.

Patient P., 32 years old, was admitted to the surgical department on December 30, 2002, case history No. 3314/52 with a diagnosis of Pancreatic head cancer T2N1M0, St-3.

Upon admission, he complains of icteric sclera and skin, itching, dark urine, acholic feces, dull pain and heaviness in the right hypochondrium. In the biochemical analysis of blood, there is an increase in bilirubin to 215.1 μm / L - total, 64.8 μm / L - direct, an increase in liver enzymes 3-4 times higher than normal. With ultrasound in the projection of the pancreatic head, a tumor-like formation of 20 × 35 mm, expansion of extrahepatic bile ducts (choledoch = 14 mm). After preoperative preparation, January 16, 2003, the operation was performed: pancreato-gastroduodenal resection. When revising the organs of the pancreatoduodenal zone during surgery: a moderately mobile tumor with a size of up to 4.0 cm in diameter is palpated in the head of the pancreas, no distant metastases were detected. It was decided to perform a radical operation. The pancreatogastroduodenal complex was removed by a standard method, the pancreas parenchyma had a soft consistency, the main pancreatic duct was not dilated, and its diameter was 2 mm. Given these circumstances, a single-row invagination pancreatogastroanastomosis was formed according to the proposed method. Further reconstruction: hepaticojejunoanastomosis, gastrojejunoanastomosis on one loop, drainage of the abdominal cavity. Histology No. 860-945: ductal carcinoma of the type of low-grade adenocarcinoma. The postoperative period was uneventful, the patient was discharged on the 14th day in a satisfactory condition.

In total, the proposed method operated on 12 patients.

All patients in the early postoperative period after restoration of the motor function of the gastrointestinal tract underwent fibrogastroduodenoscopy to assess the state of the pancreatic stump. Complications of the pancreatic stump and pancreatogastroanastomosis after surgery were not observed.

The proposed method for the formation of pancreatogastroanastomosis at the reconstructive stage of pancreatoduodenal resection provides the following advantages:

Reducing the risk of pancreatodigestive anastomosis failure by improving the blood supply to the anastomosis and reducing its trauma.

Reducing the time of surgery.

The use of this method of pancreatogastrostomy improved the immediate results of pancreatogastroduodenal resection.

Claims (1)

The method of forming pancreatogastroanastomosis with soft stump parenchyma and the diameter of the main pancreatic duct less than or equal to 3 mm, including the removal of pancreatoduodenal complex followed by invagination of the pancreas into the posterior wall of the stomach with suturing, characterized in that the incision of the posterior wall of the stomach is 1/3 less pancreatic stump, pancreatic stump intussusception is carried out to a depth of 3-4 cm, two fillet sutures and two nodal sutures are applied to the anterior and posterior flange the anastomosis of the pancreas and stomach, stepping back 4 cm from the edge of the pancreatic stump.

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