RU2465842C1 - Method for pancreatic resection in chronic pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and may be used for pancreatic resection in chronic pancreatitis. It involves applying 5-7 sutures for pancreaticoduodenal artery ligature feeding a head of pancreas along an internal duodenal loop. It is followed by crateriform excision of the central portion of the head of pancreas with Santorini's and Wirsung's ducts. A probe inserted in a lumen of the Wirsung's duct and used as a mark to excise the Wirsung's duct with surrounding changed tissues in the form of a wedge to a level of junction of the pancreas to a tail to form a gutter cavity open anteriad in pancreatic tissue to be anastomosed with the lumen of a longitudinally Roux-opened defunctioned small intestinal loop by a single-layer continuous suture.

EFFECT: method enables reducing injuries, improving quality of drainage of the pancreatic ducts.

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Description

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of chronic pancreatitis with subtotal and total damage to the pancreas.

State of the art

Currently, in the surgical treatment of chronic pancreatitis, resectional types of interventions are actively used - Beger's surgery, Frey. However, these operations are mainly used to treat pancreatitis with a predominant lesion of the pancreatic head, while in the clinic there are often patients with subtotal and total involvement of the gland parenchyma in the fibro-degenerative process. It seems relevant to develop resection interventions specifically designed for this group of patients.

As a prototype, the inventors propose a pancreatic resection method, which was proposed by C. Frey [Frey C.F., Smith G.J. Description and rationale of a new operation for chronic pancreatitis. Pancreas, 1987; 2: 701-706.]. This technique involves excision of the central portion of the pancreatic head while maintaining a narrow strip of parenchyma along the duodenum with excision of the Santorini duct and the anterior wall of the Wirsung duct. Further, between the cavity formed after removal of the pathological tissues of the pancreatic head and the lumen of the loop of the small intestine disconnected along the Ru, pancreatojejunoanastomosis is formed using a double-row suture. If additional drainage of the ductal system is necessary, the longitudinally opened duct of the Wirsung duct, such as longitudinal pancreatojejunostomy according to Partington-Rochelle, is also included in the anastomosis.

The disadvantages of this method are: incomplete drainage of the ducts of the II and III order in the body of the pancreas, excessive trauma to the gland tissue during the application of a double-row suture.

Disclosure of invention

The objective of the invention is to improve the results of surgical treatment of patients with chronic pancreatitis with subtotal and total damage to the pancreas.

The essence of the invention lies in the excision of pathologically altered body tissues of the pancreas with the complete removal of the Wirsung duct in the head and body of the gland, the use of a single-row suture to form pancreatojejunoanastomosis, and the use of the TachoComb hemostatic preparation for additional sealing of the anastomosis.

Resection is as follows. Access to the omental sac is made by crossing the gastrocolic ligament, the front surface of the pancreas is exposed. On the inner contour of the duodenum 5-7 sutures are applied for ligation of the branches of the pancreas-duodenal arteries that feed the head of the pancreas. Then, with the help of an electrocoagulator, a phased crater-like excision of the central part of the pancreatic head with Santorinia and Wirsung ducts is performed (Fig. 1). In the lumen of the Wirsung duct in the direction of the tail of the gland, a thin probe is introduced, which serves as a guide for the further course of the resection (figure 2). After this, the altered tissues of the glandular body are excised in the form of a gutter to the level of transition of the glandular body to the tail along with the Wirsung duct. As a result, in the gland tissue an anterior groove-shaped cavity is formed, into which ducts of the II and III order directly open (Fig. 3). Hemostasis is performed using electrocoagulation or by flashing individual vessels with thin atraumatic threads (5/0). Then, a loop of the jejunum disconnected along Ru is formed. The disconnected part of the intestine is opened longitudinally, and between it and the cavity formed in the pancreas an anastomosis is applied with a single-row continuous suture (atraumatic suture material 4/0 - 5/0) (Fig. 4). In order to additionally seal the anastomosis on the suture area, the application of the TahoKomb preparation plates is performed (Fig. 5). Drainage of the anastomotic zone is carried out using microjunostomy, superimposed on the anastomosed loop of the jejunum 10-15 cm distal to the anastomosis.

Brief Description of the Illustrations

Figure 1 shows a phased excision of pathological tissue of the head of the pancreas.

Figure 2 shows a probe inserted into the lumen of the Wirsung duct after resection of the pancreatic head.

Figure 3 shows a schematic view of the pancreas after removal of pathologically altered tissues of the head and body.

Figure 4 shows a schematic view of the formed pancreatojejunoanastomosis.

Figure 5 shows the sealing of the anastomosis plate TahoeKomb.

The implementation of the invention

The application of the described method for pancreatic resection in chronic pancreatitis was carried out on the basis of the surgical department of the State Clinical Hospital “Regional Clinical Hospital” of the city of Tver.

The advantages of the proposed method are:

- more complete removal of pathologically altered, non-functioning gland parenchyma;

- drainage of ducts of the II and III order;

- less trauma to the gland tissue when a single-row suture is applied;

- less time spent for the formation of the anastomosis.

Clinical example:

Patient V., 27 years old, was admitted to the surgical department of the State Clinical Hospital “Regional Clinical Hospital” with complaints of intense pain in the epigastric herpes zoster, worse after eating, accompanied by nausea, vomiting, weight loss. A history of alcohol abuse. Examination was performed: an ultrasound examination revealed an increase in the size of the head and body of the pancreas, the ducts of the Wirsung duct were not expanded. Computed tomography revealed an increase in the head of the pancreas up to 35 mm, a body up to 23 mm, expansion of the Wirsung duct, common bile duct, portal vein. In the parenchyma of the gland, a large amount of calcifications. After preoperative preparation, the patient underwent resection of the head and body of the pancreas in accordance with the above method. The duration of the operation was 160 minutes. The postoperative period was uneventful. There were no signs of failure of the anastomosis. Transparent pancreatic juice, without blood impurity, was supplied through the drainage of the pancreatojejunoanastomosis zone. The wound healed by primary intention. The drainage of the pancreatojejunoanastomosis zone was removed on the 14th day after the operation, no leakage of secretion along the channel was noted. The patient was discharged for aftercare in an outpatient setting in satisfactory condition. The patient was re-examined 3 months after discharge: noted complete relief of pain, restoration of a normal rhythm of food intake, normalization of body weight. Signs of diabetes mellitus and exocrine pancreatic insufficiency have not been identified.

Claims (1)

A method for pancreatic resection in case of chronic pancreatitis, including excision of the central part of the pancreatic head with preservation of a narrow strip of parenchyma along the duodenum with excision of the Santorini duct, characterized in that 5-7 sutures are placed along the inner contour of the duodenum for dressing the duodenum arteries feeding the pancreatic head, a crater-like excision of the central part of the pancreatic head with santorini is performed With the help of a probe inserted into the lumen of the Wirsung duct and used as a guide, the Wirsung duct with surrounding altered tissues in the form of a wedge is made up to the level of the transition of the pancreas body into the tail with the formation of the open anterior gutter cavity in the gland tissue, which anastomoses with a lumen of a longitudinally open loop of the small intestine disconnected along the Ru with a single-row continuous suture, sealing of the anastomosis by application of the plates of the TahoKomb preparation, drainage anastomosis zone through mikroeyunostomu superimposed 10-15 cm distal to the anastomosis.

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