RU2432130C1 - Method for prevention of purulent complications in surgical management of chronic pancreatitis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to surgery, and can be applied for prevention of purulent complications in surgical management of chronic pancreatitis. A flap is made of a right half of epiploon. A window exceeding a pancreatic wound defect by 1-2 cm is formed in an avascular centre of the epiploon flap. An internal border of the epiploon flap is fixed to a pancreatic capsule around the wound defect by single interrupted suture with a pitch 6-8 mm. Creation of a pancreatoenteroanastomosis is followed by formation of an omental sac drained to the outside. A border of the omental sac enveloping a segment of a small intestine is sutured to an intestinal wall. Free borders of the flap are sutured together above the pancreatoenteroanastomosis with a hole left in the middle of a suture line. Two emmisaries are introduced through the left hole into a cavity of the formed omental sac. A hole of the omental sac is sutured The emmisaries are delivered outside. ^ EFFECT: method allows reducing risk of inflammatory and purulent complications. ^ 1 ex, 5 dwg

Description

The invention relates to medicine, in particular to surgery, and can be used in the surgical treatment of chronic pancreatitis.

Currently, for the surgical treatment of chronic pancreatitis, resection and drainage operations are generally accepted, the purpose of which is to eliminate the pathological focus, reduce intraductal pressure, and as a result, relieve pain. So, during resecting operations, a pathologically altered head of the gland is removed with the formation of an anastomosis between the stump of the pancreas and jejunum (Whipple A., 1946, Traverso L., Longmire W., 1978, Beger H., 1980, Frey C., 1987), and in draining operations (Duval M., 1954, Puestow C., Gillesby W., 1958, Partington R., Rochelle R., 1960), decompression of the ductal system is achieved due to the formation of pancreatoenteroanastomosis. With pronounced dilatation of the main pancreatic duct in complicated chronic pancreatitis, the longitudinal pancreatoenteroanastomosis technique with the creation of the widest possible internal pancreatic drainage is widely recognized (Puestow C., Gillesby W. // Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis // Arch. Surg, - 1958. - Vol. 52. - P.898-907). According to the literature, the above methods are effective in 70% of patients with chronic pancreatitis, including those with complicated forms (Beger HG et al. // Adv Surg, - 1999, - Vol.32, P.87-104, Fitzsimmons D. et al Ann J Gastroenterol, - 2005, Vol.100: 4, P.918-926), however, 30% in the postoperative period develop purulent-inflammatory complications (But H., Frey C // Arch. Surg. - 2001. - Vol.136. - P.1333-1338, Adams D., Ford M., Anderson B. // Ann. Surg. - 1994. - Vol.5. - P.481-489, Nealon W., Thompson J // Ann. Surg. - 1993. - Vol.217. - P.459-468, Schnelldorfer T., Lewin D., Adams D. // World J. Surg. - 2006. - Vol.30. - P .1321-1328), which reduces the effectiveness of the surgical treatment of chronic pancreatitis.

A known method of surgical treatment of chronic capitate pancreatitis (RF patent No. 2228720, 05.20.2004), including median laparotomy and mobilization of the pancreatic head according to Kocher, characterized in that the capsule is longitudinally dissected and the surface layer of the pancreatic parenchyma along the front surface of the head is intraparenchymally removed mass from the head of the pancreas leaving a parenchymal-capsular framework 0.5-0.7 cm thick, dissecting the anterior wall of the pancreatic duct, which opens formed cavity with subsequent isolation of a segment of the small intestine and its anastomosis with parenchymal-capsular frame bounding the cavity of the head of the pancreas and the pancreatic duct.

The disadvantage of this method is the need to form proximal pancreatoenteroanastomosis with inflammatory tissue of the pancreatic head, which increases the risk of purulent complications in the abdominal cavity in the postoperative period due to the failure of the joints of the anastomosis.

A known method of longitudinal pancreatoenteroanastomosis, designed to perform anastomoses of the pancreas with the small intestine, often with complicated chronic pancreatitis (RF patent No. 2296517, 09.03.2005). Dissect the main pancreatic duct by performing a longitudinal section from the head to the tail along the front surface of the pancreas. Throughout the section through equal distances, the pancreas parenchyma is excised in the form of fragments of a triangular shape with bases on a longitudinal section and peaks facing the upper and lower edges of the pancreas. At the same time, cavities, gaps and branches of the main pancreatic duct are opened together with first-order pancreatic ducts, forming a dentate surface. Anastomosed pancreatic resected area with a loop of the small intestine.

A known method of forming pancreatoenteroanastomosis with pancreatoduodenal resection with unchanged pancreatic tissue (RF patent No. 2272576, 03/27/2006), including the installation of a catheter in the main pancreatic duct, sealing the duct system of the resected pancreas, characterized in that after removal of the pancreatic pancreatic pancreatic complex to the upper and lower edges of the peritoneum covering the stump of the pancreas, after installing a catheter in the main duct of the pancreas e o fix with one suture to the duct of the gland, and then lay on the serous cover of the small intestine and at a distance of 1-1.5 cm from the pancreatic section above the catheter, gray-serous nodal sutures are placed with the formation of the tunnel, then the intestine is opened at the end of the tunnel, the catheter they are carried out into the intestinal lumen, the puncture zone is sealed, and the catheter is brought out through the blind end of the intestine to the anterior abdominal wall, and the drainage-foam system is brought to the pancreatic cut section, the catheter is removed 2-4 months after the operation.

The known method of the recovery phase after medial resection of the pancreas (RF patent No. 2363395, 08/10/2009), including medial resection of the pancreas, mobilization of the loop of the small intestine with the formation of a circular vicious circle by applying end-to-side enteroanastomosis at its end segment, characterized in that from the main pancreatic duct in the region of the distal and proximal stump, fragments of a triangular shape are turned, facing the bases to each other, and two pancreates are applied bilaterally icoenteroanastomosis on a loop of the small intestine formed in a circular vicious circle.

A known method of pancreaticostomy (RF patent No. 2371119, 10.27.2009), which includes carrying out pancreaticostomy drainage in the lumen of the small intestine, characterized in that after removing the drug during pancreatoduodenal resection, the end hole in the small intestine is sutured with double-row sutures tightly, the serous layer is dissected. a distance of 15 cm from the blind end longitudinally, forming a hole in the serous layer equal in diameter to the diameter of the pancreatic stump, the upper semicircle of the serous cr the intestine in the area of the opening, the omentum, the section of the pancreatic stump, the lower semicircle of the serous edge of the intestine, the sutures tighten, form the stuffing box between the section of the pancreatic stump and the intestine, form in the submucosal layer of the small intestine a blunt path from the hole in the serous layer over 13 cm in the direction of the blind end of the intestine, a silicone drainage tube extending from the stump of the pancreatic duct is passed through the formed channel and brought to the skin, the blind end of the small intestine is sutured to the anterior b the tissue wall of the separate abdominal sutures around the drainage tube removed to the skin, 1 month after surgery under local anesthesia, the anterior abdominal wall tissue is dissected in the area of the removed silicone drainage tube to the hemmed intestine, a hole is formed in the intestine, silicone drainage is immersed in this intestine, and the intestinal hole is sutured tightly, sutured the wound of the abdominal wall.

The above methods do not exclude the risk of leakage of the joints of the anastomosis, the formation of inflammatory infiltrate or abscess in the intervention area, peritonitis and other purulent complications of the abdominal cavity.

Closest to the present invention is a method for the surgical treatment of chronic capitate pancreatitis (Frey C., Smith G. Description and rationale of new operation for chronic pancreatic. Pancreas, 1987, vol. 2, p. 701). The essence of the prototype method consists in opening the pancreatic duct in the area of the pancreas body, resection of the anterior part of the pancreatic head, opening the pancreatic duct in the area of the pancreatic head, anastomosing an isolated loop of the small intestine with pancreatic duct in the area of the body and head. Illustration of the method in the application - Figure 1.

This method does not exclude the possibility of developing infiltrative and purulent-septic complications in the area of surgical intervention in case of leaking pancreaticenteroanastomosis, especially in situations where the reliability of the anastomosis directly depends on the state of the stitched tissues.

The objective of the invention is to develop a method for the prevention of purulent complications in the surgical treatment of chronic pancreatitis, an effective prophylactic complication of the underlying disease and eliminating inflammatory and purulent-septic complications in the area of surgical intervention and the abdominal cavity.

The problem is solved by the method of prevention of purulent complications in the surgical treatment of chronic pancreatitis. According to the standard method, a sectoral resection of the pancreatic head and longitudinal pancreatotomy are performed, after which a flap is harvested from the right half of the greater omentum; in the central avascular part of the omental flap, a “window” is 1-2 cm larger than the wound defect of the pancreas, inner edge the omental flap is fixed to the capsule of the pancreas around the wound defect with single interrupted sutures with a seam pitch of 6-8 mm, after application of pancreaticenteroanastomosis over the anastomosis of alnikovogo flap formed drained out "the packing bag" to isolate the anastomosis zone free from the abdominal cavity.

The technical result of using this technique is the elimination of complications of chronic pancreatitis: pain, stenosis of the duodenum and common bile duct, compression of retro-pancreatic and main intestinal vessels, prevention of inflammatory, infiltrative and common (diffuse) purulent-septic complications of the abdominal pancreatic erythematosus.

The use of an "stuffing bag" drained outwardly effectively prevents the development of abscesses and infiltrates beyond, which reduces the risk of involvement of the adjacent organs in the pathological process with subsequent violation of their function.

The resorptive properties of the omentum contribute to the reduction and faster resolution of inflammatory phenomena in the area of operation.

Thus, the new methods we developed for the prevention of purulent complications in the surgical treatment of chronic pancreatitis help to reduce the recovery time for patients with chronic pancreatitis and reduce mortality.

The invention is illustrated by the following figures 1-4:

Figure 1. Performed a sectoral resection of the pancreatic head and longitudinal pancreaticotomy.

Figure 2. A flap was prepared from the right half of the greater omentum, a “window” was formed in the central avascular part of the omental flap, the flap was fixed to the capsule of the pancreas.

Figure 3. Formed pancreaticenteroanastomosis on the loop of the small intestine turned off from the digestion along the Ru.

Figure 4. An “stuffing bag” has been formed. The final type of operation.

Designations adopted in the figures:

1 - pancreatic wound,

2 - “window” of the gland flap,

3 - suture fixation of the omental flap to the capsule of the pancreas,

4 - loop of the small intestine,

5 - interintestinal anastomosis,

6 - suture fixation of the omental flap to the small intestine,

7 - seams of the stuffing bag,

8 - rubber graduates,

9 - half-mesh seams,

10 - Contrapper with rubber graduates.

A detailed description of the method and an example of its clinical implementation

According to the generally accepted technique, median laparotomy is performed. In order to assess the technical feasibility of the operation, an audit is made of the gastropancreatoduodenal complex, liver and biliary tract, retroperitoneal fiber, and intestinal great vessels. Access the anterior surface of the pancreas. According to the standard method, sectoral resection of the pancreatic head and longitudinal pancreatotomy with opening of the lumen of the main pancreatic duct are performed (Figure 1). Parenchyma hemostasis is performed in the area of resection of the head and pancreatotomy zone by piercing of bleeding vessels.

The next step, without disturbing the blood supply, harvest a flap from the right half of the greater omentum (Figure 2). The omentum flap is placed above the pancreas so that its central part is projected onto the pancreas wound (Figure 2, item 1), after which a “window” is formed 1-2 cm larger than the size of the pancreatic wound in the central avascular part of the omental flap. (Figure 2, item 2). Using single interrupted sutures of a monolithic thread through 6-8 mm, the inner edge of the gland flap is fixed to the capsule of the pancreas, retreating from the edge of the wound of the gland by 7-10 mm (Figure 2, 3).

In the upper floor of the abdominal cavity, through the window into the mesocolon, a loop of the small intestine is turned off from the digestion along the Ru (Fig. 3, item 4). A single-row pancreaticenteroanastomosis is formed with single interrupted sutures. The continuity of the gastrointestinal tract is restored by the formation of the intestinal anastomosis of the type "end to side" (Figure 3, 5).

The next step in the omental flap is pancreatoenteroanastomosis. The edge covering the outlet segment of the small intestine is fixed with single interrupted sutures to the wall of the intestine (Figure 4, item 6). The free edges of the flap are sutured together by single sutures above the pancreaticenteroanastomosis (Figure 4, item 7), while in the central part of the suture line, a hole with a diameter of up to 1 cm is left. The formation of the “stuffing bag” is completed. Through the hole left in the cavity of the "stuffing bag" enter two rubber graduates and bring them to the pancreatoenteroanastomosis (Figure 4, 8). On the opening of the "stuffing bags" impose 2 half-mesh seam (Figure 4, item 9).

The next step is to pierce the anterior abdominal wall in the left hypochondrium, rubber graduates are brought out through the contra-aperture (Figure 4, item 10). With the help of half-mesh seams, the “stuffing bag” with rubber graduates is fixed from the inside to the peritoneum in the area of contraperturation, thereby isolating the “stuffing bag” cavity from the free abdominal cavity. The operation is completed by drainage of the abdominal cavity and layer-by-layer suturing of the postoperative wound.

Clinical example

Patient S, 24 years old, and.b. No. 4570, was admitted to the department of reconstructive plastic surgery of the OKB on 6.04.10, with a diagnosis of chronic calculous pancreatitis, cysts of the head and body of the pancreas. According to the claimed method 04/14/10 performed the operation: laparotomy, sectoral resection of the pancreatic head with the formation of pancreaticenteroanastomosis on the loop of the small intestine turned off along the Ru, isolation of the anastomosis zone with an “stuffing bag”. The postoperative period was uneventful. During control examinations, laboratory and instrumental data without gross violations. The patient was discharged in satisfactory condition 15 days after surgery. One month after the operation, the condition is satisfactory. On SKT: the pancreas is not enlarged, the pancreatic duct is not enlarged, cystic transformation of the gland tissue was not detected. The patient gained weight, there are no dyspeptic and endocrine disorders, there is no pain, the ability to work is restored.

The method we developed was used in 6 patients operated on for chronic pancreatitis. Postoperative complications and deaths were not observed. Recovery of patients occurred in a shorter time due to the lack of infiltrative and inflammatory changes in the intervention zone. Own experience has shown the high efficiency of the proposed method in the surgical treatment of chronic pancreatitis.

The advantages of the proposed method for the prevention of purulent complications in the surgical treatment of chronic pancreatitis:

1. Effectively eliminates the complications of chronic pancreatitis: pain, stenosis of the duodenum and common bile duct, compression of retro-pancreatic and major intestinal vessels.

2. Allows you to reduce the frequency of postoperative complications in the form of purulent complications of the abdominal cavity and the mortality rate.

3. Helps to reduce the recovery time of patients with chronic pancreatitis and improve the quality of life of patients.

The method of surgical treatment of chronic pancreatitis has been tested in a clinic and can be recommended for use in surgical practice in specialized hospitals.

Claims (1)

A method for the prevention of purulent complications in the surgical treatment of chronic pancreatitis, including sectoral resection of the pancreatic head and longitudinal pancreatotomy, characterized in that a flap is harvested from the right half of the greater omentum, a “window” is formed in the central avascular part of the omental flap, 1-2 cm larger pancreatic wound defect, the inner edge of the gland flap is fixed to the pancreatic capsule around the wound defect with single interrupted sutures in increments the suture is 6-8 mm, after application of pancreaticenteroanastomosis, an “stuffing bag” is drained outward, as follows: the edge of the gland flap, covering a segment of the small intestine, is fixed with sutures to the intestinal wall, the free edges of the flap are sutured together above the pancreaticenteroanastomosis, in this case the seam lines leave a hole, two graduates are introduced into the cavity of the formed “stuffing bag” through the hole left, seams are put into the opening of the “stuffing bag”, graduates are brought out.

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