RU2336832C2 - Method for pancreaticoduodenal resection at locally invasive cancer in periampullary area with tumoral invasion of portal and upper mesentric vein - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: two heterolateral big hypodermic veins, testicular or ovarian veins are used as autovenous prosthetic device. Specified above veins preliminary longitudinal dissect, extracorporally form united autovenous conduction and without it reversion both ends of the conduction are anastomised with stumps of upper mesenteric and portal veins. Stump of lienal vein is sewed into a side of autovenous conduction.

EFFECT: provision of possibility of reconstruction of veins of mesenteric and hepatoportal system after their extensive resection and to restore mesenteric and hepatoportal blood-groove.

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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 portal and superior mesenteric veins.

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. Moreover, 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 portal and superior mesenteric veins.

The method for reconstruction of the portal vein after its resection in case of its tumor invasion when performing pancreatoduodenal resection (Yu.A. Nesterenko, A.V. Prikazchikov, Current trends in the surgical treatment of pancreatic cancer patients // Annals of Surgical Hepatology Vol. 4. - No. 2 - 1999. - S.13-22), which is carried out as follows: for tumor invasion of the portal vein at the level of splenic and superior mesenteric vein inflow into it, the splenic vein is ligated (without splenectomy) in combination with oksimalnoy and distal resection of the diseased segment of the portal vein, and reconstruction is effected by autovenous graft from the iliac vein.

Disadvantages:

a) ligation of the splenic vein leads to a reduction in portal blood flow by at least 50%, which leads to the development of hepatic parenchyma ischemia, hepatic cell failure;

b) ligation of the splenic vein leads to a decrease in linear and volume velocity in the portal system, which entails venous thrombosis in the anastomotic zone;

c) sampling of an autovenous conduit from the iliac vein significantly increases the duration and invasiveness of the operation, the size of the operative blood loss, requires the expansion of surgical access and mandatory reconstruction of the iliac vein, is accompanied by the risk of severe thrombotic complications in this venous pool (ileofemoral thrombosis, inferior vena cava syndrome, pulmonary embolism );

d) when using an iliac vein graft, the problem of the mismatch between the diameters of the conduit and the stumps of the resected veins often arises.

As the closest analogue, the method of reconstruction of the superior mesenteric vein after its resection in case of its tumor invasion during pancreatoduodenal resection (A.A.Shalimov et al., Intervention on the portal vein during pancreatic resection // Bulletin of Surgery named after Grekov, - № 11. - 1987. - P.52-56.), Which is carried out as follows: after removal of the tumor with the superior mesenteric vein segment as a single unit, the superior mesenteric vein is reconstructed using the autovenous insert from the large saphenous hips under the control of the diameter of the lumen and the location of the graft valves.

Disadvantages:

1) taking into account the fact that the diameter of the great saphenous vein of the thigh corresponds to the diameter of the superior mesenteric, and especially the portal vein, only in isolated cases, this reconstruction method cannot be applied with extensive tumor invasion of the portal and superior mesenteric veins;

2) the use of this method, as a rule, will be accompanied by a decrease in the linear and volume velocity of blood flow, which leads to a high risk of thrombotic complications of the main veins;

3) if the mouth of the portal vein is damaged, implantation of the splenic vein into the autovenous conduit from the large saphenous vein of small diameter is impossible.

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 extensive resection;

2) to restore the mesenteric-portal blood flow as close to physiological as possible.

To solve the tasks after circular resection of the portal and superior mesenteric veins as a single unit with the pancreatoduodenal complex, their autovenous prosthetics are performed, and two contralateral large saphenous veins of the thigh or testicular (ovarian) veins, which are previously longitudinally dissected, form an extracorporeal one as an autogenous prosthesis. conduit and without its reversion, both ends of the conduit anastomose with stumps of the superior mesenteric and portal veins, the stump of the splenic of the vein is sewn into the side of the autovenous conduit.

In relation to the closest analogue of the claimed method has the following technical result. An adequate reconstruction of the veins of the mesenteric-portal system is carried out after their extensive resection with restoration of the mesenteric-portal blood flow, which is as close as possible to the physiological one.

The method is illustrated in figures 1-3, where 1 is the superior mesenteric vein; 2 - portal veins; 3 - splenic vein; 4 - segment of the great saphenous vein of the thigh (testicular vein); 5 - extracorporeally formed autovenous conduit; 6 - anastomosis between conduit and portal vein; 7 - anastomosis between the superior mesenteric vein and conduit; 8 - anastomosis between the splenic vein and conduit.

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 extensive tumor invasion of the terminal sections of the superior mesenteric (1), splenic (3), initial portal vein (2), and the portal vein formation site, a single block is resected with pancreatoduodenal complex of the portal, splenic and superior mesenteric veins under conditions of their complete clamping (figure 1). After this, an autovenous prosthesis is made extracorporeally (5), for the formation of which two contralateral large saphenous veins of the thigh or testicular (ovarian) veins are used (4). Veins are taken according to one of the generally accepted methods. The veins are longitudinally dissected and extracorporeally form a single autovenous cylindrical conduit of the required diameter by longitudinal stitching of the dissected veins with a monofilament non-absorbable suture on atraumatic needles (Fig. 2). Further, without reversion of conduit, both its ends anastomose with stumps of the superior mesenteric (7) and portal veins (6). After the resumption of mesenteric-portal blood flow, the stump of the splenic vein is sutured into the side of the autovenous conduit (8) with lateral squeezing (Fig. 3), for which a single autovenous conduit is pre-positioned with suture lines anterior and posterior.

After this, the digestive tract is reconstructed using 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 extensive tumor invasion of the portal and superior mesenteric veins 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 16.1% 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 R., 53 years old, was admitted to the hospital with a diagnosis of locally advanced pancreatic head cancer with invasion of the superior mesenteric and portal veins. 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 and superior mesenteric veins in a single block with a tumor, lymphadenectomy. The reconstruction of the main veins of the mesenteric-portal system was carried out by the claimed method using biautovenous conduit from the great saphenous vein of the thigh. The gastrointestinal tract was reconstructed by the formation of an end-loop 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, vein patency 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 extensive invasion of the portal and superior mesenteric veins, to carry out an adequate and most physiological reconstruction of the resected vessels.

Socio-economic importance. The developed method can significantly improve the operability and long-term survival of patients with locally advanced periampicular cancer, improve the immediate and long-term results of radical surgical treatment of periampicular tumors with extensive invasion of the portal and superior mesenteric veins.

Claims (1)

The method of pancreatoduodenal resection in case of locally advanced cancer of the periampicular region with tumor invasion of the portal and superior mesenteric veins, including circular resection of the portal and superior mesenteric veins as a single unit with pancreatoduodenal complex, followed by their autovenous prosthesis and reconstruction of the digestive tract, using two contralateral large saphenous veins of the thigh, testicular or ovarian veins, which are previously extended about dissected extracorporeally autovenous form a single conduit and without reversing its both ends a conduit with anastomose the stumps of the superior mesenteric and portal vein, splenic vein stump sewn into the side autovenous conduit.

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