RU2393780C1 - Method of preventing pancreatitis and necrosis of pancreas stump after pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, surgery, in particular pancreas surgery and can be applied in order to prevent pancreatitis and necrosis of pancreas stump after pancreatoduodenal resection. For this purpose supra-median laparotomy is performed, pancretoduodenal complex is isolated and ablated. 20 cm from small intestine stump lower semi-circle of pancreas stump is sewn to intestinal wall by means of six sutures. Into pancreatic duct PVC drainage with diametre corresponding to duct diametre is introduced for 4-5 cm. Drainage tube is fixed to duct wall by means of purse-string suture. In small intestine wall puncture is made. Purse-string suture is applied. PVC drainage is passed through enterotomic opening in small intestine lumen and is brought out through stump at whose end one more purse-string suture is applied. Threads of earlier applied purse-string sutures of enterotomic opening and small intestine stump are tied. Small intestine wall is sewn to upper semi-circle of pancreas stump with six sutures. 1 In left subcostal area anterior abdominal wall is punctured. Through puncture end of PVC drainage is brought on skin. Small intestine stump is fixed with four interrupted sutures from inside to peritoneum, end of PVC drainage being fixed on skin. In the wall of PVC drainage external ring single opening with diametre constituting 1/3 of drainage diametre is made. Through the opening into drainage lumen thin ureter catheter is introduced, passed along pancreatoduodenal drainage and introduced into pancreatic duct on its full depth. To external end of ureter catheter system for infusions is switched. Drainage-washing system is adjusted.

EFFECT: increase of efficiency of pancreatitis and pancreas stump necrosis prevention after pancreatoduodenal resection.

1 ex, 4 dwg

Description

The invention relates to medicine, surgery, in particular pancreatic surgery, and can be used to prevent pancreatitis and necrosis of the pancreatic stump after pancreatoduodenal resection.

According to Patyutko Yu.I. et al. the incidence of pancreatodigestive anastomosis failure is 1.2-23% (Patyutko Yu.I., Kotelnikov A.G., Abgaryan M.G. Modern surgical and combined treatment of patients with exocrine cancer of the pancreatic head and organs of the periampicular zone. // Practical Oncology . - 2004. - T.5, No. 2. - S.94-107). The risk of developing postoperative complications in this area is largely due to the initial state of the pancreatic stump. In the vast majority of patients with localization of the tumor in the head of the parenchyma, the glands are soft, juicy and friable in section. The main pancreatic duct is rarely expanded to more than 3-4 mm and has thin, easily damaged walls. A more favorable variant of the initial state of the pancreatic stump is created by fibrotic changes in the parenchyma and often the concomitant expansion of the main pancreatic duct with a densification of its wall. A wide variety of options for the state of the remaining pancreas, a high risk of developing postoperative pancreatitis or pancreatodigestive anastomosis failure with severe consequences caused the use of numerous methods for including the gland stump in the digestive tract or, on the contrary, completely shutting it out of the digestion up to performing total pancreatectomy (V.N. Polysalov, 2007).

A known method of pancreatoduodenal resection, which is based on the imposition of anastomoses of the common bile duct and pancreatic stump with a loop of the small intestine turned off according to Ru (Littmann I. Abdominal surgery. - Budapest, 1970. - p. 493).

The disadvantage of this method is the lack of sufficient decompression of both choledocho-, gastroenteroanastomoses, and pancreatoenteroanastomosis. Due to the fact that the anastomoses between the choledochus and the intestine, the pancreatic stump and the intestine are superimposed on one loop, there is a constant adverse effect of bile on the pancreatoenteroanastomosis zone.

There is a method of performing pancreatoduodenal resection, in which a “reservoir” is created from the small intestine, the lumen of which is anastomosed with the stump of the pancreas, common bile duct, stomach, while the cavity of the reservoir is drained by a nasogastric tube for 1 day and thus all digestive juices from the lumen of the gastrointestinal tract (Patyutko Yu.I., Klimenkov AA, Itin AB, Samoilenko VM - Surgery. - 1990. - No. 2 - C.133-135).

However, the described method has significant disadvantages.

When performing the operation according to this method, from the lumen of the intestinal reservoir, all juices entering there are removed by one drainage, which does not guarantee complete evacuation of the secret from the pancreatic and bile ducts due to the possibility of edema of the latter, especially in the area of anastomoses, which leads to the aggressive effect of bile and pancreatic juice on the line sutures of the anastomosis and can lead to the development of cholangitis, acute postoperative pancreatitis, failure of the anastomoses. In addition, the evacuation of contents from the gastrointestinal tract by this method is carried out only during the day after the operation, and intestinal paresis and consequently the need for decompression of the latter after pancreatoduodenal resection remain for 4-5 days after the operation.

There is a method of pancreatojejunostomy by invagination of the pancreatic stump into the lumen of the intestine with its subsequent fixation, demucosis of the intestine within the invaginate, drainage of the anastomosis zone and the creation of an antireflux valve from the intestinal wall (Shalimov SA, Nichitailo ME, Zakharov IB The technique of pancreatojejunostomy for pancreatoduodenal resection. Surgery. - 1991, No. 7, pp. 117-119).

However, these methods do not exclude the development in the postoperative period of pancreatitis, pancreatic necrosis, failure of the anastomosis, stricture of the stump of the excretory duct of the pancreas.

A known method of external percutaneous pancreaticostomy for pancreatoduodenal resection (RF patent No. 2154424, 08/20/2000), including the formation of the “blind” end of the jejunum after removal of the pancreatoduodenal complex, suturing the posterior semicircle of the pancreas section to the intestinal wall, draining the drainage duct of the main pancreas drainage carried out through the intestinal lumen in the proximal direction, the removal of drainage through the anterior abdominal wall with cutaneous fixation, the hemming of the anterior semicircles of a cut of the gland to the intestinal wall, stitching of the sutured end of the intestinal loop to the inner surface of the abdominal wall, characterized in that the duct system of the pancreas is sealed by applying a purse string suture around the drainage and using a balloon catheter with an inflated cuff located in the lumen of the pancreatic duct as drainage with a purse string suture, drainage into the intestinal lumen through a puncture of the intestinal wall, not exceeding the diameter of the drainage, is isolated from the free abdominal polo STI drainage removed from the lumen of the intestine by the application of covering gray-serous sutures.

A known method of pancreato-gastroduodenal resection (RF Patent No. 2158546, 10.11.2000), including mobilization of the pancreatoduodenal complex, resection of the pancreatic head, duodenum, single-stitched suture on the stump of the intestine, resection of the part of the stomach, application of endoscopic pancreatic pancreatitis gastroeyunoanastomosis of the type "end to side", choledochojunoanastomosis of the type of "end to side", with invagination of the stump of the bile duct in the intestinal lumen and drainage of the bile duct, characterized in that they impose pancreas toyunal anastomosis on the frame drainage, one end of which is inserted into the lumen of the Wirsung duct, fixing it with a ligature, and the second is passed through a single-row suture of the intestinal stump into its lumen, through gastrojejunoanastomosis, stomach, esophagus and outward through the nose, while the sutured intestinal stump is sutured to the capsule of the pancreas with two rows of nodular gray-serous sutures, invaginating it, gastroyunoanastomosis is imposed in the lesser curvature of the stomach along the resection line and form a “spur” in the greater curvature of the stomach, choledochojejunoanastomosis n lay, invaginating the stump of the common bile duct in the intestinal lumen with two rows of gray-serous sutures on the walls of the common bile duct and intestines without stitching the mucous membranes so that the stump of the common bile duct hangs freely in the lumen of the intestine, and the bile duct is drained by frame drainage through the intestinal lumen and an incision in the intestinal wall into the anterior abdominal wall.

A known method of forming pancreatic enteric anastomosis during pancreatoduodenal resection (RF patent No. 2195204, 12/27/2002), including the imposition of an anastomosis between the pancreas and jejunum, characterized in that the main pancreatic duct is cannulated with a plastic tube and strengthened with a U-shaped suture in the duct through the suture in the duct a hole in the mesentery of the loop of the small intestine is carried out by a pancreatic stump, then the loop of the intestine is sewn to the capsule of the gland along the perimeter of the stump with a two-row suture, forming a sleeve from the small intestine around the gland, after through a puncture in the diverting pipe is carried foot ulcers and fix its ends to the gut threads U-shaped seam, and then ligated resulting diverter knee stump over between a two-lane gland seal.

A known method of forming pancreatic enteric anastomosis during pancreatoduodenal resection (RF patent No. 2195207, 12/27/2002) by forming an invagination terminological pancreatojejunoanastomosis, characterized in that prior to suturing the intestine and the pancreatic duct, the ducts are catheterized into the gland through the tube, and continuous shuttle invaginating suture, while the first and last injections are made on the intestine.

The disadvantage of the above methods is that the drainage of the pancreatic duct system implies passive abduction of an aggressive environment, which does not reduce the risk of pancreatodigestive anastomosis failure, inflammation and autolysis of pancreatic tissue in the early postoperative period.

A known method for the prevention of acute pancreatitis after direct operations on the pancreas (RF patent No. 2191595, 10.27.2002), including the use of a drug that inhibits pancreatic secretion, characterized in that trypsin is used as an agent that inhibits pancreatic secretion by introducing it into the intraduodenal concentrations of 0.1-0.2 mg / kg of patient body weight with an interval of 6-8 hours through an intraoperatively installed probe in the duodenum.

The disadvantages of this method include the fact that the introduction of an agent that inhibits pancreatic secretion is carried out in the duodenum through the probe, and not intrapancreatically, while the drug is administered fractionally, which does not provide the proper inactivating concentration of the drug in the lumen.

A method has been developed for the formation of termolateral pancreatojejunoanastomosis, including drainage of the pancreatic duct by microdrainage with its fixation in the anastomosis region and sealing of the opening in the intestine with simultaneous stitching of the intestinal wall to the pancreas with a continuous S-shaped semi-net seam with atraumatic V-long dissolving. The absence of lateral holes in the microdrainage on the segment of the intestinal lumen, distal to the anastomosis region, excludes the possibility of the intestinal contents being thrown into the pancreatic duct, eliminating the possibility of the activating effect of enterokinase (or bile) on pancreatic juice enzymes, and thereby reduces the possibility of pancreatitis (V.N. Polysalov The method of forming termolateral pancreatojejunoanastomosis during gastropancreatoduodenal resection. // Herald of Surgery. - 2007. - T.166, No. 1. - P.55-59).

The prototype of the claimed invention, we have selected a method of external percutaneous pancreaticostomy for pancreatoduodenal resection described in the patent of the Russian Federation No. 2154424, 2000

These disadvantages are eliminated in the claimed invention.

The objective of the invention is to develop a method for the formation of pancreatojejunoanastomosis, which allows to prevent complications by reducing trauma to the pancreas and increasing the integrity of the anastomosis.

The task is achieved by the fact that according to the standard method, the upper middle laparotomy is performed, the pancreatoduodenal complex is isolated and removed. 20 cm from the stump of the small intestine hem the lower semicircle of the stump of the pancreas to the intestinal wall with six sutures. In the pancreatic duct at 4-5 cm, PVC drainage is introduced with a diameter corresponding to the diameter of the duct. The drainage tube is fixed to the duct wall with a purse string suture. A puncture is performed in the wall of the small intestine. Impose a purse string suture. PVC drainage is carried out through the enterotomy hole into the lumen of the small intestine and is removed through its stump, at the end of which another purse string suture is applied. The threads of the previously imposed purse string sutures of the enterotomy opening and stump of the small intestine are tied. The wall of the small intestine is sutured to the upper semicircle of the pancreatic stump with six sutures.

In the left hypochondrium, the anterior abdominal wall is pierced. Through a puncture, the end of the PVC drainage is brought out onto the skin. The stump of the small intestine is fixed with four interrupted sutures from the inside to the peritoneum, and the end of the PVC drainage on the skin. A single hole with a diameter of 1/3 of the diameter of the drainage is made in the wall of the outer end of the PVC drainage. A thin ureteral catheter is inserted through the opening into the drainage lumen, which is carried out through pancreaticostomy drainage and is introduced into the pancreatic duct to its entire depth. An infusion system is connected to the outer end of the ureter catheter. Establish a drainage and flushing system.

The technical and economic effectiveness of the method lies in the fact that the removal of digestive juices from the gastrointestinal tract in the early stages after surgery with their subsequent return to the intestinal lumen prevents the development of homeostasis disorders, failure of anastomoses and peritonitis. The presence of a tube with holes in the anastomosis zone of the pancreatic cyst with the intestine protects the anastomosis from the action of aggressive media, eliminates the development of purulent-septic complications, and facilitates the postoperative period of the patient.

Thus, the immediate results of surgical treatment of patients with cancer of the pancreas and periampicular zone are improved.

The essence of the method is illustrated by drawings, where figure 1-4 shows:

Figure 1. The initial stage of the application of pancreaticojejunostomy, the introduction of a drainage tube into the pancreatic duct.

Figure 2. The stage of conducting the drainage tube through the jejunum segment and removing it through the enterostomy.

Figure 3. The final stage of the application of pancreaticoeunoanastomosis, the formation of a suspended enterostomy, the removal of a drainage tube to the anterior abdominal wall, the introduction of an irrigation catheter into the distal portions of the pancreatic duct through the drainage tube.

Figure 4. Stage of establishing a washing system.

A detailed description of the method and examples of its clinical application.

By the standard method, the upper middle laparotomy is performed, the pancreatoduodenal complex is isolated and removed. At the stage of formation of pancreatoenteroanastomosis according to the “end to side” type, they initially deviate from the stump of the small intestine (1) by 20 cm and with six atraumatic sutures 3/0 (4) the lower semicircle of the pancreatic stump (2) is sutured to the intestinal wall. Then, PVC drainage (6) with a diameter corresponding to the diameter of the duct, with drainage holes opening only into the lumen of the duct, is introduced into the pancreatic duct (3) by 4-5 cm. The drainage tube is fixed to the duct wall with a purse string suture (5) with a thin Vikril thread, thereby sealing the duct system in order to prevent pancreatic juice from entering the anastomosis zone.

In the wall of the small intestine, strictly opposite to the pancreatic duct, a puncture is performed. A purse string suture (8) is placed around the formed enterotomy opening (7). After this, PVC drainage (6) is carried out through the enterotomy hole into the lumen of the small intestine and a stump is brought out through it, at the end of which there is another purse string suture (9). Next, the threads of the previously imposed purse string sutures of the enterotomy opening and stump of the small intestine are tied, thus preventing intestinal contents from entering the pancreatoenteroanastomosis and abdominal cavity. A pancreatic section is covered with a wall of the small intestine, which is hemmed to the upper semicircle of the section with six 3/0 atraumatic sutures (10).

The next step is to pierce the anterior abdominal wall in the left hypochondrium. Through a puncture, the end of the PVC drainage is brought out onto the skin. The stump of the small intestine with the drainage located in it is fixed with four interrupted sutures (11) from the inside to the peritoneum, and the end of the PVC drainage (6) on the skin. Further, a single hole with a diameter of 1/3 of the diameter of the drainage is made in the wall of the outer end of the PVC drainage. A thin ureteral catheter (12) is inserted through the hole into the drainage lumen, which is carried out through pancreaticostomy drainage (6) and is introduced into the pancreatic duct (3) to its entire depth. An infusion system is connected to the outer end of the ureter catheter, thereby establishing a drainage-flushing system.

In the early postoperative period, for 10 days, a constant solution of 10 ml of Gordox is administered in 500 ml of 0.25% Novocaine at a rate of 20 drops / min, thereby inactivating the aggressive action of pancreatic juice enzymes.

On the 10th day, a thin ureteric catheter is removed, and passive drainage of pancreatic juice to the outside is carried out by means of thick PVC drainage. On the 30-45th day (with a favorable course of the postoperative period) after the resorption of the purse string suture on the pancreatic duct, the pancreaticostomy drainage is removed.

Clinical example

Patient A-s, 62 years old, and.b. No. 1254, was admitted to the Department of Reconstructive Plastic Surgery OKB 03/12/07, with a diagnosis of cancer of the head of the pancreas. 03/14/07 performed the operation: gastropancreatoduodenal resection, formed pacreatoentero-, choledochoentero- and gastroenteroanastomosis according to the claimed method. In order to prevent pancreatitis and pancreatic stump necrosis after pancreatoduodenal resection in the early postoperative period for 10 days, the inactivating solution was continuously injected into the pancreatic duct according to the described method. Over the next 20 days after removal of the washing system, passive drainage of pancreatic juice was carried out, after which pancreaticostomy drainage was removed. The postoperative course corresponded to the severity of the surgery. The patient was discharged in satisfactory condition 30 days after surgery. At the control examination after 3 months, the patient's condition is satisfactory.

We developed a method for the prevention of postoperative pancreatitis and pancreatic stump necrosis after pancreatoduodenal resection was used in 5 patients operated on for pancreatic head cancer, which underwent gastropancreatoduodenal resection. Postoperative complications and deaths were not observed. Own experience has shown the high efficiency of the proposed method in the prevention of pancreatitis and necrosis of the pancreatic stump in patients of this group.

The advantages of the proposed method:

1. The tightness of pancreatodigestive anastomosis excludes the entry of aggressive pancreatic juice into the anastomosis zone, contributing to its smooth healing.

2. The decrease in the activity of pancreatic juice enzymes, its removal using the washing system, reduces the risk of pancreatodigestive anastomosis failure.

3. The constant introduction of Gordox's solution into the pancreatic ductal system in the early postoperative period neutralizes pancreatic juice enzymes, thereby preventing inflammation and autolysis of pancreatic tissues.

The proposed method is optimal for the formation of pancreatodigestive anastomosis after pancreatoduodenal resections performed for malignant tumors of the pancreatoduodenal region or pancreatic injuries.

The results obtained allow us to consider it appropriate to use the developed method of pancreatoduodenal resection in wide clinical practice. The inventive method can be widely used in any surgical department, does not require special tools.

Claims (1)

A method for the prevention of pancreatitis and pancreatic stump necrosis after pancreatoduodenal resection, including the formation of a “blind” end of the jejunum after removal of the pancreatoduodenal complex, suturing of the posterior semicircle of the pancreatic section to the intestinal wall, draining the main pancreatic duct through perforated plastic drainage , drainage through the anterior abdominal wall with cutaneous fixation, hemming of the anterior shelf for cutting the gland to the intestinal wall, suturing the sutured end of the intestinal loop to the inner surface of the abdominal wall, sealing the pancreatic duct system by applying around the drainage of the purse string suture, conducting drainage into the intestinal lumen through a puncture of the intestinal wall, not exceeding the diameter of the drainage, isolation from the free abdominal cavity drainage removed from the lumen of the intestine, characterized in that 20 cm from the stump of the small intestine hem the lower semicircle of the stump of the pancreas to the intestinal wall of the sessile At the sutures, PVC drainage with a diameter corresponding to the diameter of the duct with drainage holes opening only into the duct lumen is inserted into the pancreatic duct at 4-5 cm, PVC drainage is carried out through the enterotomy opening into the lumen of the small intestine and the stump is brought out through it, at the end of which one purse string suture, the threads of the previously applied purse string sutures of the enterotomy opening and the stump of the small intestine are tied, the wall of the small intestine is sutured to the upper semicircle of the pancreatic stump with six sutures, in the thin wall the stitches are punctured directly opposite the pancreatic duct, the end of the PVC drainage is brought out to the skin through the puncture, a single hole with a diameter of 1/3 of the diameter of the drainage is made in the wall of the outer end of the PVC drainage, a purse string suture is inserted, a thin ureteral catheter is inserted into the drainage lumen, which is carried out by pancreaticostomy drainage and is introduced into the pancreatic duct to its entire depth, an infusion system is connected to the external end of the ureter catheter and a constant ction inactivating solution in the pancreatic duct in the early postoperative period.

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