RU2368327C1 - Method of treating retroduadenal perforations after endoscopic papillosphincterotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery. Laparotomy is performed. Cholecystectomy and choledochotomy are performed. Duodenum is mobilised after Kocher. Choledoch is drained with T-shaped drainage. T-shaped drainage is selected in accordance with width of choledoch distal part. First, upper drainage branch is introduced. Then lower drainage branch is introduced through intrapancreal part of choledoch and created during papillosphincterotomy choledochoduodenal fistula into duodenum lumen. After which duct wall is sutured to drainage from below.

EFFECT: method allows to improve results of surgical treatment of said category of patients due to ensuring outer bile discharge in post-operation period and complete covering of perforation opening without its search and suturing.

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Description

The invention relates to medicine, in particular to surgical surgery. Endoscopic papillosphincterotomy is a necessary intervention in patients with complicated cholelithiasis. However, the manipulation of BDSK and the dissection of its ampoule are not without the danger of developing serious complications - bleeding, pancreatitis, retroperitoneal perforation. Complications associated with EPST arise in 0.6-23.4% (Potashov L.V., Kudrevatykh I.P., Schetinin V.N., Poliglotov O.V., Khristolyubiv A.V. Complications of papillosphincterotomy and their Prevention, Moscow International Congress on Endoscopic Surgery, Abstracts edited by Professor Yu.I. Gallinger, Moscow, April 24-26, 2002; 2 / 8-2 / 9, Sedov A.P., Parfenov I.P., Lutsenko V. .D., Karpachev A.A., Mishustin AM, Tatyanenko T.N. Endoscopic papillotomy: mistakes and failures. Annals of surgical hepatology. Perm, 2001, S.162-163).

Retroperitoneal perforation is extremely rare, but the consequences of its development are sometimes fatal for the patient (99% die on the third day after surgery). Some authors believe that with retroroduodenal perforation, it is sufficient to perform nasobiliary drainage of the common bile duct. Other researchers for the treatment of this category perform laparotomy, choledochotomy, search and suturing of the perforated hole, drainage of the choledochus, abdominal cavity and retroperitoneal space (Freemar ML, Nelson DB, Sherman S. Haper GB et al. Complications or endoscopic biliari sphincterotomy. N Eng J Med 1996; 335; 909-918).

The disadvantages of the known methods are that the search for the hole is inconclusive, especially with the so-called “posterior” or intraperitoneal perforations, when the dissection of the BSDK ampule is made with a needle papillotome. Suturing perforation in the development of retroperitoneal phlegmon is doomed to failure. The use of nasobiliary drainage in the treatment of retroperitoneal perforations (retroduodenal perforations in endoscopic dissection of the large papilla of the duodenum. B. S. Briskin, P. V. Ektov, A. G. Kartsev, A. E. Ivanov, Yu. F. Klymenko. Endoscopic surgery , 1, 2003, S.30-34) does not limit the inflammatory process and contributes to the further development of phlegmon and peritonitis. It is not acceptable for intraperitoneal perforation, as the authors themselves indicate.

For the prototype, a method was selected for the treatment of patients with calculous cholecystitis in combination with benign pathological changes in the bile ducts and the large duodenal papilla. The method consists in the fact that after performing a laparotomy, cholecystectomy, choledocholithotomy, choledoch drained by a T-shaped drainage, proposed by the German surgeon Kerr.

The objective of the invention is to expand the arsenal of funds for the treatment of retroperitoneal perforations of the duodenum after EPST.

The solution to the problem is that when performing a laparotomy for retroperitoneal perforation of the duodenum after endoscopic papillosphincterotomy, standard cholecystectomy, choledochotomy, choledocholithotomy are performed, and the duodenum is mobilized according to Kocher. The difference of the proposed method is that the surgery is completed by draining the choledochus with a T-shaped drainage according to Kerr, which is selected strictly in accordance with the width of the distal bile duct. Moreover, after the introduction of the upper branch of the drainage, the lower is installed through the intrapancreatic part of the common bile duct in the choledochoduodenal anastomosis created during endoscopic papillosphincterotomy into the lumen of the duodenum.

Figure 1 - view of the installed drainage in the frontal plane.

Figure 2 - view of the installed drainage in the sagittal plane.

The method is as follows. When performing a laparotomy for retroperitoneal perforation of 1 duodenum after endoscopic papillosphincterotomy, standard cholecystectomy, choledochotomy, choledocholithotomy are performed, and the duodenum is mobilized according to Kocher. Surgery is completed by draining the choledochus 2 with a T-shaped drainage 3 according to Kerr (Fig. 1, 2), moreover, the drainage 3 is selected strictly in accordance with the width of the distal bile duct 2. When installing drainage, the upper branch of the drainage is introduced first, and the lower one is established through the intrapancreatic part of the choledoch into the choledochoduodenal anastomosis created during endoscopic papillosphincterotomy in the lumen of the duodenum 4, which is never done with the classical method of drainage of the common bile duct. This technique prevents the likelihood that the in-duct parts of the drainage may wrap. In the proposed method, the drainage in addition to performing its main function - unobstructed discharge of bile, also performs the function of tightly closing the perforation hole. The correctness and tightness of standing of the intraductal parts is checked by control cholegraphy. The duct wall is sutured with an atraumatic needle and a polysorb thread (4/0 or 5/0). Suturing of the duct is performed before drainage from below. Drainage in the duct is held for 21 days. During this time, the patient receives sandostatin from the first day after surgery.

Example. Patient S., 57 years old, medical history No. 3846 / D, was admitted 20.10.2005 with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. Choledocholithiasis. Acute biliary pancreatitis. 10.21.2005 ERCP + EPST. A few hours after surgical treatment, signs of retroperitoneal perforation appeared: abdominal pain and subcutaneous emphysema on the face and upper body. An emergency procedure was performed laparotomy, cholecystectomy from the neck, drainage of the common bile duct by the proposed method. Discharged on 11/14/05 in satisfactory condition. Inspected after a month. There are no complaints.

Thus, performing drainage of the common bile duct in this way allows you to:

- to provide external bile duct in the postoperative period, reducing pressure in the lumen of the duodenum;

- to achieve complete closure of the perforation by selecting the size of the drainage and intrapancreatic part of the common bile duct;

- not to resort to searching and suturing the perforation, which is extremely difficult in the conditions of developed retroperitoneal phlegmon or peritonitis;

- improve the results of surgical treatment of this category of patients.

Claims (1)

A method of treating retroperitoneal perforations of the duodenum after endoscopic papillosphincterotomy, characterized in that a laparotomy, cholecystectomy, choledochotomy are performed, the duodenum is mobilized according to Kocher, the bile duct is drained by a T-shaped drainage, while the T-shaped duct is drained to the left and right to the left and right the upper drainage jaw is introduced, then the lower drainage jaw is inserted through the intrapancreatic part of the common bile duct into the one created by endoscopic papillosphincterotomy oledohoduodenalnoe fistula into the duodenum, and then sutured to the wall of the duct drainage below.

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