RU2317019C1 - Method for pancreatoduodenal resection in case of locally-metastasing cancer of periampullar area along with tumor invasion of anterior wall of portal vein's mouth - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should fulfill the resection of portal vein in the form of a rhombus with dissected anterior-lateral walls of terminal department of splenic vein under conditions of complete squeezing out portal, the superior mesenteric and splenic veins. With two contralateral ligatures it is necessary to suture, starting from the superior and the inferior spleno-portal angles, left edges of the resected portal and the superior mesenteric vein and corresponding walls of the resected splenic vein. Ligatures should be bound together. With one ligature one should suture right-handed edges of the resected walls of portal and the superior mesenteric vein together by forming a single T-shaped anastomosis. This enables to fulfill adequate venous reconstruction of mesentericoportal system and save the circulation along splenic vein.

EFFECT: higher efficiency.

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Description

The present invention relates to medicine, namely to surgery, and can be used for surgical treatment of locally advanced cancer of the periampicular region with tumor invasion of the anterior wall of the portal vein mouth.

Malignant formations of the periampicular region due to the high frequency of local spread of the tumor are characterized by very low resectability - about 16-20%. This is largely due to the relatively late onset of symptoms, the meager manifestation on the part of laboratory parameters and the difficulty in diagnostic interpretation of the initial changes in the head of the pancreas. At the same time, despite the improvement of modern diagnostic methods for visualizing focal lesions, immunological and genetic screening methods, the frequency of locally advanced cancer of this localization reaches 47.6%.

Radical operations with locally advanced cancer of the periampicular region with invasion of the main veins of the mesenteric-portal system are extremely rare and only in isolated clinics. The limitations in the operation are largely due to the lack of effective technologies for resection and reconstruction of the main veins, taking into account the high variability of their tumor lesions. These circumstances largely determine the relevance of the development of surgical technologies for advanced pancreatoduodenal resection in locally advanced periampicular cancer with extensive tumor invasion of the main veins of the mesenteric-portal system.

There is a method of reconstruction of the portal vein after its resection in case of its tumor invasion when performing pancreatoduodenal resection (A.A.Shalimov et al. Surgery, No. 9, 1977. - P.97-100), which is carried out as follows: with lateral marginal resection the walls of the portal vein mouth with a length of up to 1 cm compress the damaged area with a large heart clamp and suture transversely with an atraumatic thread.

Disadvantages:

a) When using this method, it is impossible to perform plastic closure of the defect of the anterior wall of the portal vein orifice and the site of confluence of the superior mesenteric and splenic veins.

The closest analogue is the method of reconstruction of the portal vein after its resection in case of its tumor invasion during pancreatoduodenal resection (A.A.Shalimov et al. Grekov Bulletin of Surgery, No. 11, 1987. - P. 52-56), which is carried out as follows: in the case of tumor invasion of the portal vein wall with a length of 2 to 4 cm, after its resection, the integrity of the vessel is restored by suturing a patch from an autovein from a large saphenous vein of the femur with an atraumatic thread.

Disadvantages:

a) the need for sampling autoveins leads to an increase in the duration and morbidity of the operation;

b) the duration of the reconstruction of the portal vein mouth, which is fraught with the development of hepatic parenchyma ischemia, hepatic cell failure, vein thrombosis of the mesenteric-portal system;

c) with a defect in the anterior wall of the mouth of the portal vein of irregular shape or with spreading to the splenic vein, the application of the method is difficult.

Tasks:

1. to develop a method of pancreatoduodenal resection in locally advanced periampicular cancer, providing for adequate reconstruction of the veins of the mesenteric portal system after resection of the portal vein mouth;

2. maintain blood flow through the splenic vein to ensure portal portal blood flow close to physiological.

To solve the tasks after removal of the pancreatoduodenal complex, along with a tumor and resection of the anterior wall of the portal vein mouth, autoplasty and reconstruction of the digestive tract are performed to prevent narrowing of the portal vein mouth after plastic surgery, preserve blood flow through the splenic vein and reduce the time of vascular reconstruction the portal vein is performed in the form of a versatile rhombus with excision of the anterolateral walls of the final section of the splenic vein under After squeezing the portal, superior mesenteric and splenic veins, then the left edges of the resected portal and superior mesenteric veins with the corresponding walls of the resected splenic vein are sutured with two contralateral threads, starting from the upper and lower splenic-portal angles, and the threads are connected to each other, after which one of the threads stitch the right edges of the resected walls of the portal and superior mesenteric veins with each other, forming a single T-shaped anastomosis.

In relation to the closest analogue of the claimed method has the following technical result. The proposed method for pancreatoduodenal resection in locally advanced periampicular cancer allows for adequate reconstruction of the veins of the mesenteric portal system after resection of the portal vein mouth and to maintain blood flow through the splenic vein to ensure portal physiological blood flow close to physiological.

The method is illustrated in figure 1-4, where figure 1: 1 - portal vein, 2 - splenic vein, 3 - superior mesenteric vein, 4 - defect of the mesenteric-splenoportal confluence, 5 - antero-lateral walls of the terminal section of the splenic vein; figure 2: 6 - contralateral threads on atraumatic needles; Fig. 3: 7 - threads before binding to each other; figure 4: 8 - the right edge of the resected portal vein, 9 - the right edge of the resected superior mesenteric vein.

The method is as follows. An extended total median laparotomy with hardware access correction is performed. In the process of traditional mobilization of the pancreatoduodenal complex, an intraoperative study is performed, during which the size and location of the tumor, the presence and extent of tumor invasion of the main veins of the mesenteric-portal system and their individual anatomical features are clarified. After that, in the presence of tumor invasion of the final section of the superior mesenteric, splenic, initial section of the portal vein and the site of formation of the portal vein, a single block is resected with pancreatoduodenal complex of the anterior portal wall (1), splenic (2) and superior mesenteric veins (3) under conditions of their full clamping (figure 1). After resection, the defect of the anterior wall of the mesenteric-splenoportal confluence has the form of an irregular rhombus (4) with excised antero-lateral walls of the final section of the splenic vein (5). Next is the plastic defect. For this, two contralateral monofilament filaments on atraumatic needles (6), starting from the upper and lower splenic-portal angles, suture the left edges of the resected portal and superior mesenteric veins with the corresponding walls of the resected splenic vein (Fig. 2). The threads are interconnected (7, figure 3). After this, one of the threads sutures the right edges of the resected walls of the portal (8) and superior mesenteric (9) veins to each other, thereby forming a single T-shaped anastomosis (Fig. 4).

Then, the digestive tract is reconstructed according to one of the available methods with the formation of pancreato-entero-, gastro-entero- and choledocho-enteroanastomoses.

The inventive method of surgical treatment of locally advanced periampicular pancreatic cancer with tumor invasion of the portal vein mouth was tested in 8 patients. At the same time, all patients underwent extended pyloropreserving pancreatoduodenal resection. There was no hospital mortality. A complicated course of the early postoperative period was observed in 17.6% of cases, and there were no thrombotic complications in this group of patients.

The possibility of practical use of the proposed method is illustrated by an example of its implementation in clinical practice.

Example 1. Patient Z. 72 years old was admitted to the hospital with a diagnosis of locally advanced pancreatic head cancer with invasion of the portal vein mouth. According to instrumental examination data for the presence of distant metastases have not been received. The operation was performed: Expanded pyloric preserving pancreatoduodenal resection, resection of the portal vein mouth in a single block with a tumor, lymphadenectomy. The reconstruction of the portal vein mouth was carried out by the claimed method. Reconstruction of the gastrointestinal tract was carried out by the formation of conceptual pancreatoenteroanastomosis, gastroenteroanastomosis, end-to-side choledocho-enteroanastomosis and end-to-side enteroanastomosis on one loop. The postoperative period was uneventful. The patient was discharged from the hospital in a relatively satisfactory condition on the 15th day after the operation. After surgery, the patient was repeatedly examined. 3 years after the operation, the condition is satisfactory, no data for relapse of the disease have been identified. The patency of the reconstructed veins of the mesenteric-portal system is satisfactory.

Thus, the application of the proposed method allows for radical surgery in patients with locally advanced periampicular pancreatic cancer with tumor invasion of the portal vein mouth, to carry out an adequate and most physiological reconstruction of the resected vessels.

Socio-economic importance. The developed method allows to significantly increase the operability and long-term survival of patients with locally advanced periampicular cancer, to improve the immediate and long-term results of radical surgical treatment of periampicular tumors with invasion of the portal vein mouth.

Claims (1)

The method of pancreatoduodenal resection in case of locally advanced cancer of the periampicular region with tumor invasion of the anterior wall of the portal vein mouth, including the removal of pancreatoduodenal complex together with the tumor and resection of the anterior wall of the portal vein mouth with subsequent autoplasty and reconstruction of the digestive tract, characterized in that the cavity is resected in the form of a rhombus with excised anterolateral walls of the final section of the splenic vein under conditions of complete squeezing of the portal, the superior mesenteric and splenic veins, then the left edges of the resected portal and superior mesenteric veins with the corresponding walls of the resected splenic vein are sutured with two contralateral threads, starting from the upper and lower splenic-portal angles, the threads are connected together, after which the right edges are sutured the resected walls of the portal and superior mesenteric veins with each other, forming a single T-shaped anastomosis.

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