RU2453280C1 - Method of quadrihepaticojejunostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to field of surgical hepatology. Wide laparotomy from bisubcostal incision is performed, hepatoduodenal ligament is exposed, common bile duct is cut and ligated in supraduodenal part. Proximal stump of hepaticocholedoch is isolated before bifurcation. Sparing resection of liver of Taj Mahal type is performed. Silicone stents are installed into intrahepatic ducts. Biliodigestive anastomosis is formed by bringing open end of disabled by Roux loop of jejunum to liver porta. Ends of intestine around orifice of intrahepatic bile ducts are sewn to tissues of hepatodupdenal ligament, sero-muscular layer of gallbladder and liver capsule.

EFFECT: method ensures application of physiological anastomosis between bile ducts and small intestine, reduces risk of development of post-operative complications: biliary peritonitis, restenosis.

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Description

The invention relates to medicine, namely to the field of surgical hepatology, and can be used for radical treatment of hilus tumors of the liver.

In case of obstruction in the area of fusion of the hepatic ducts and proximal to restore the free flow of bile, it is required to excise biliodigestive anastomoses with intrahepatic bile ducts after excision of cicatricial strictures or hilus tumors (in case of radical surgery). In this situation, the most appropriate operations are many authors (Shalimov A.A. et al., 1975; Vinogradov V.V. et al., 1977; Halperin E.I. et al., 1982; Y. Shifumi Kovardi et al., 2001; MI Prudkov et al., 2007;) consider hepatopathyunostomy with stitching of the adjacent both hepatic ducts on the frame drains leading to the anterior abdominal wall of the ends of the drains according to Voelcker, or on “hidden” drains; hepaticoyunoanastomosis according to Ru; hepatikoejunoanastomoz according to Velikoretsky; hepaticoyunoanastomosis according to A.A.Shalimov; hepaticoyunoanastomosis according to Smith-Grass; by Sitenko-Nechay; by Kirtley; hepaticoyunoanastomosis according to Cole; hepaticoyunoanastomosis Zockler; Brown hepaticoyunoanastomosis; hepaticoyunoanastomosis according to Halperin, intrahepaticojejunostomy (4 anastomoses) according to Yushifumi. Kawarda and Bidhan Chandra with gentle liver resection (“Taj Mahal resection”), etc.

Description of the prototype. As a prototype, a method was taken, an intrahepaticojejunostomy, formed with sparing liver resection of the Taj Mahal type, described by Yushifumi Kawarda, Bihan Chandra (sparing liver resection in hilus bile duct cancer // Annals of surgical hepatology. - 2001. - T6. - No. 1. - C .11-18).

Signs of the prototype

1. Partial internal removal of bile.

2. The possibility of prevention of remodeling of digestion by clamping the drainage.

3. Providing external decompression of the biliary tract for the healing period of biliary digestive anastomoses.

Criticism of the prototype.

The main disadvantage of intrahepatic jujunostomy with four intrahepatic bile ducts is the possible restenosis of anastamoses.

The second, no less significant drawback of the method is the technical complexity of the formation of four biliodigestive anastomoses with fairly closely located bile ducts.

Patients with obstructive jaundice of tumor origin are in a state of activity, the plastic properties of tissues are sharply suppressed. Under these conditions, there is a risk of anastomotic failure and there is a high risk of developing biliary peritonitis.

When biliodigestive anastomoses are formed on the frame drains leading to the anterior abdominal wall, complete external removal of bile is observed, since the drains are in the biliary tract for a long time (sometimes up to a year, having a high risk of anastomosis restenosis). This often leads to remodeling of digestion, electrolyte-electrolyte disturbances and exhaustion of patients.

Thus, the identified disadvantages of the prototype include the following:

1. Technical complexity.

2. The risk of developing biliary peritonitis.

3. The risk of developing dyspeptic syndrome.

4. The risk of developing the syndrome of electrolyte disturbances.

5. High risk of developing restenosis of biliodigestive anastomoses.

In this regard, the search for less complicated anestomoses and restenosis of the method of internal bile removal, in which bile would completely enter the gastrointestinal tract, seems to be relevant.

The aim of the invention is to improve the results of radical treatment of tumors of the bile ducts of hilus localization.

SUMMARY OF THE INVENTION

To implement the method, a wide laparotomy is performed from the double-rib incision, the place of the incision according to Fedorov after the laparotomy is used to isolate the hepatoduodenal ligament, then the common bile duct and it is crossed and ligated in the supraduodenal part. The left and right hepatic arteries are covered by vascular turnstiles, the main trunk of the portal vein is isolated completely from the surrounding tissues before its bifurcation. The proximal stump of hepatic choledochus is secreted before bifurcation with the intersection of the cystic duct. At the same time, the cystic artery is retained. A subserosal cholecystectomy is performed so that a sufficiently thick serous-muscular layer remains in the neck and cystic hepatoduodenal junction. Next, the operation - tumor resection is performed in the same way as in the prototype - sparing liver resection such as Taj Mahal. Then, silicone stents 10-12 cm long are installed in all 4 intrahepatic ducts and a biliodigestive fistula is formed by bringing the open end of the loop of the jejunum turned off along the Ru to the gate of the liver and stitching the edge of the intestine around the mouth of the intrahepatic bile ducts around the peritoneum of the hepatoduodenal ligament, sero-muscular a layer of the gallbladder and a capsule of the liver. The distal ends of the stents are freely located in the lumen of the jejunum loop turned off along the Ru.

Comparative characteristics of the essential features of the prototype and invention are shown in table

Prototype Invention one. Laparotomy with a double-rib incision. one. Laparotomy with a double-rib incision. 2. Isolation of hepatoduodenal ligament, common bile duct, vascular formations. 2. Isolation of hepatoduodenal ligament, common bile duct, vascular formations. 3. Mobilization of the left lobe of the liver and caudate. 3. Mobilization of the left lobe of the liver and caudate. four. Drawing a line of separation of the liver with an electrocoagulator. four. Drawing a line of separation of the liver with an electrocoagulator 5. Liver resection. 5. Liver resection. 6. Formation of a biliodigestive anastomosis with each hepatic duct and excretion of the ends of frame drains through the jejunum to the anterior abdominal wall. 6. The formation of biliodigestive anastomosis by bringing the open end of the loop of the jejunum turned off along the Ru to the gate of the liver, stenting of the bile ducts into the lumen of the turned off intestine . 7. Partially internal removal of bile. 7. Internal removal of bile .

Distinctive features of the invention and prototype.

1. The formation of biliodigestive anastomosis with the open end of the loop of the jejunum by suturing the edge of the intestine around the mouth of the intrahepatic bile ducts around the peritoneum of the hepatoduodenal ligament, the serous-muscular layer of the gallbladder and capsule of the liver.

2. The distal ends of the stents are freely located in the lumen of the jejunum loop turned off along the Ru, and are not brought to the anterior abdominal wall.

3. Complete internal removal of bile, in which there is no remodeling of digestion.

Application in the clinic.

We developed a method for the formation of biliodigestive anastomosis, based on the formation of an anastomosis between the segmental ducts of the bile tree of the liver and the end of the jejunum turned off according to Ru, which allows performing internal bile diversion into the gastrointestinal tract, was used in the clinic in the treatment of 6 patients with guillous liver cancer. In all cases, a favorable outcome was noted, no complications were noted.

An example of a specific implementation.

Patient M., 50 years old, was admitted to the General Surgery Clinic of Dagmedacademia with the diagnosis: “A tumor of extrahepatic bile ducts of the Klatskin type. proximal obstruction of the biliary tract. "

From the anamnesis: the patient considers himself about a month when there were complaints of yellowness of the skin, discomfort in the epigastrium.

On admission: the condition is closer to satisfactory, the skin is clean, icteric, vesicular breathing over the lungs, heart sounds are rhythmic, muffled, A / D - 130/80 mm Hg, pulse - 76 min. The abdomen on palpation is soft, moderately painful in the epigastrium, the liver is slightly enlarged.

Ultrasound: a liver of 16.5 cm, of a homogeneous structure, with diffuse changes, intrahepatic bile ducts expanded to 0.8-1.0 cm, enlarged lymph nodes in the projection of the portal of the liver, gall bladder as a reduced one, a section of hyperechoic formation in the projection of the distal Department of the common bile duct.

CT: signs of volumetric formation of the gate of the liver, cholangiocarcinoma? Cholestasis with expansion of the intrahepatic bile ducts.

Laboratory data: hemoglobin 108 g / l; erythritol. 4.0 g / l; ESR 68 mm / h; white blood cells - 5.6 g / l; blood sugar 6.4 mmol / L; bilirubin 319 mmol / l (direct 125); ALT 0.18 mKAT (h); ACT 0.27; total protein 73 g / l; blood amylase 7.4 mg / sec. 06/25/2011, Operation-Laparotomy, resection of a trifurcation tumor of the bile ducts, hepaticojejunoanastomosis with a jejunum loop turned off along the Ru on “frame drains”. Entero-enteroanastomosis.

Under general anesthesia, a laparotomy was performed with an incision according to Lachey-Spasokukotsky. The liver is enlarged, greenish in color, expanded subcapsular bile capillaries are determined. The gall bladder is empty. During the audit of extrahepatic bile ducts, a tumor 2.5 × 2.0 cm in size was detected in the area of bile duct confluence (Klatskin tumor). The tumor is resected within the limits of healthy tissues, cholecystectomy is performed. At the same time, 4 ducts opened. They are wide and “white” bile flows through them. Stents (silicone) were installed in the ducts and hepatikoejunoanastomosis was applied with the jejunum loop turned off along the Ru. Entero-enteroanastomosis end to the side. The subhepatic space and the pelvis are drained with silicone tubes. Layered seams on the wound.

Preparation: gall bladder 6.0 × 2.0 cm in size, no bile in the lumen. The tumor is 2.5 × 2.0 cm in size, in a whitish section. These structures were sent for histological examination.

P / o diagnosis: Cholangiocellular carcinoma of the bile duct confluence (Klatskin tumor), proximal obstruction of the biliary tract. Obstructive jaundice.

The postoperative course is smooth. Safety drainage removed on the 7th day. Histologic conclusion: scirrhoid adenocarcinoma of the bile duct, adenomatosis of the gallbladder wall, pericholatic hepatitis with cholestasis.

Laboratory studies after treatment: hemoglobin 85 g / l; erythritol. 3.2, CPU 0.8; ESR 78 mm / h; total bilirubin 50 μmol / l (direct 42); total protein 60 g / l; Alkaline phosphatase 1876 units; glucose 4.5 mmol / l.

In satisfactory condition, the patient was discharged under the supervision of a surgeon and oncologist at the place of residence with recommendations.

The positive effect of the application of the proposed method.

1. Anastomosis between the bile ducts and the gastrointestinal tract is formed in a more physiological version by creating an anastomosis between the bile ducts and small intestine, i.e. carried out internal abstraction of bile.

2. Biliodigestive anastomosis is formed with less technical difficulties (given the possible presence of 3 to 8 intrahepatic bile ducts).

3. The risk of developing postoperative complications is reduced: biliary peritonitis (as a result of failure of anastomoses), restenosis.

4. Mortality is significantly reduced and the length of hospital stay of patients is reduced.

Sources of information taken into account

1. A.A.Shalimov, A.P. Radzikhovsky, V.N. Polupan. Atlas of operations on the liver, biliary tract, pancreas and intestines. M .: Medicine, 1979 - C - 179-184.

2. Kubyshkin V.A., Vishnevsky V.A. Pancreatic cancer - Moscow, 2003 - 375 p.

3. Shalimov A.A., Domansky B.V., Klimenko G.A., Shalimov S.A. Surgery of the liver and bile ducts - Kiev, 1975. - 408 p.

4. Yushifumi Kavarda, Bihan Chandra. (Gentle liver resection in hilus bile duct cancer // Annals of surgical hepatology. - 2001. - T6. - No. 1. - C.11-18). - prototype.

Claims (1)

The method of quadrhepaticojejunostomy, which consists in the isolation of the hepatoduodenal ligament, common bile duct, vascular formations, characterized in that they form a biliodigestive anastomosis by bringing the open end of the loop of the jejunum turned off along the Ru to the gate of the liver, bile ducts are stented into the lumen of the turned off intestine.