RU2472456C1 - Method of treating diseases and traumatic injuries of extrahepatic bile ducts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. After formation of biliodigestive anastonosis on drainage gastrojejunoanastomosis is applied. 3-4 cm long cut on stomach is made in transverse direction in medium third of stomach in close proximity to lesser curvature. On small intestine cut is made in longitudinal direction at distance 8-10 cm from applied biliodigestive anastomosis.

EFFECT: method makes it possible to carry out post-operative endoscopic correction of biliodigestive anastomoses.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of iatrogenic injuries of the extrahepatic bile ducts, in the elimination of strictures, cholangitis, etc. diseases and traumatic injuries of the extrahepatic bile ducts (VLP).

Treatment of intraoperative injuries of the extrahepatic bile ducts remains a difficult task requiring extensive experience and skill of the surgeon. Recently, an increase in cases of injuries and strictures of the bile ducts has been noted, which is associated with an increase in the specific gravity of laparoscopic cholecystectomy.

The most common methods of surgical treatment of patients with iatrogenic damage to ALV are biliodigestive anastomoses on the frame drains, which allow creating a fairly wide anastomosis between the bile ducts and small intestine, ensuring unhindered flow of bile from the intrahepatic ducts into the lumen of the intestinal tube ("Guide to Bile duct surgery." Edited by E.I. Galperin, P.S. Vetshev, 2006, p. 523-557).

All existing methods not only do not exclude, but in most cases involve repeated surgical interventions in connection with the inevitable complications, the most severe of which are strictures of biliodigestive anastomoses. To correct the complication that has arisen, such manipulations are used as balloon dilatation, bougienage or stenting of the stricture zone through the transhepatic drainage or endoscopically through the juvenile stem.

A known method of hepaticojejunostomy according to Ru (RF Patent No. 2263476, IPC АВВ 17/11, publ. 2005), used in the treatment of strictures of extrahepatic bile ducts, including paracostal access in the right hypochondrium, allocation of the stricture zone of hepatic choledochus, search for the initial section of the small intestine using laparol , the formation of an intestinal anastomosis according to Ru and a biliodigestive anastomosis on the loop of the small intestine turned off by Ru.

The disadvantage of this method is that with the development of postoperative hepatikojunoanastomosis strictures, there is no possibility of correcting complications by non-surgical methods (balloon dilatation, bougienage or stenting of the stricture zone). These manipulations require repeated surgery under anesthesia.

The closest is a method of surgical treatment of bile duct injuries (Tulin A.I., Zeravs N., Kupchs K. Endoscopic and percutaneous transhepatic stenting of the bile ducts. Materials of the XIV International Congress of Surgeons-Hepatologists. Annals of Surgical Hepatology. 2007. V.12, No. 1, p. 57), including the application of a biliodigestive anastomosis (BDA) on the loop turned off along the Ru, fixation of the sutured end of the small intestine to the subcutaneous tissue of the anterior abdominal wall, catheterization of the bile ducts, stenting of the intrahepatic bile ducts.

The disadvantage of this method is the need to search for the hemmed blind end of the loop turned off by Ru in an operational way, at least in the amount of mini-laparotomy. Intervention requires anesthesia. The patient is subjected to additional surgical trauma, requiring appropriate postoperative rehabilitation.

The objective of the invention is to eliminate these drawbacks, improve the results of surgical treatment of patients with iatrogenic injuries and diseases of the extrahepatic bile ducts, improve the quality of life of patients and complete social rehabilitation by providing the possibility of correction of strictures of biliodigestive anastomoses, when they occur, non-surgical, minimally invasive, endoscopic manipulations ( balloon dilatation, bougienage or stenting of the stricture zone).

To this end, in a method for treating diseases and traumatic injuries of the extrahepatic bile ducts, including applying a biliodigestive anastomosis, disabling a portion of the small intestine, draining the bile ducts, it is proposed to impose a biliodigestive anastomosis on internal frame drains (stents) on a loop disconnected along the Roux or on a long loop with Brown, and then impose gastroyunoanastomoz with the blind end disconnected according to Ru or with a discharge loop disconnected according to Brown of the small intestine. In this case, an incision on the stomach is made in the transverse direction in the middle third of the stomach in close proximity to the lesser curvature 3-4 cm long, and an incision is made on the small intestine of an adequate length in the longitudinal direction at a distance of 8-10 cm from the applied biliodigestive anastomosis. The distal ends of the drains are left in the lumen of the small intestine or are removed through the opening of the gastroejunoanastomosis into the cavity of the stomach.

The method is as follows.

During the operation, depending on the nature of the damage or the disease of ALV, a biliodigestive anastomosis is applied on the internal frame drains (stents) on a loop disconnected along the Ru or on a long loop with Brown anastomosis. Then superimposed gastroeyunoanastomosis with a blind end disconnected according to Roux or with a discharge loop disconnected according to Brown of the small intestine.

Gastroejunoanastomosis is performed according to known methods with a two-row suture.

The features of the anastomosis are: an incision on the stomach for the formation of anastomosis is made in the transverse direction in the middle third of the stomach in close proximity to the lesser curvature, 3-4 cm long. An incision of an adequate length on the small intestine is made in the longitudinal direction at a distance of 8-10 cm from the applied biliodigestive anastomosis. In this case, the distal ends of the drains can be left in the lumen of the small intestine involved in the formation of the anastomosis or can be brought out through the opening of the gastroejunoanastomosis into the cavity of the stomach.

After completion of the formation of a biliodigestive anastomosis (3-4 weeks after the initial operation), gastrojunoscopy is performed with an examination of the anastomosis zone (BDA) and the frame drainage is removed.

Subsequently, in the event of strictures, relapses of cholelithiasis, endoscopic minimally invasive interventions can be performed to correct the anastomosis: in the form of dilatation, lithoextraction, stenting, and others.

We present clinical observations.

Example 1

Patient V., A.I., born in 1947, and / b No. 18538, was admitted to the surgical department with a diagnosis of unformed external bile fistula.

Anamnesis: Operated at the place of residence for acute destructive cholecystitis on the 7th day after the onset of the disease. Cholecystectomy was performed with technical difficulties. During the operation, during the separation of the “cervical” infiltrate, bleeding occurred, which was stopped by flashing a bleeding vessel. In the postoperative period, on the 3rd day after the operation, bile duct appeared along the drainage from the abdominal cavity. Reoperated (09/10/2010) - relaparotomy, in which a subhepatic leak was revealed. The source of bile leakage was not identified. Sanitation and drainage of the subhepatic space was performed.

Upon receipt, the state of moderate severity.

On examination:

- Excessive fistulography: the wound course of the drainage, which communicates with the lobar ducts of both lobes of the liver at the gate level, is contrasted. Hepatic choledochus does not contrast;

- MRI of the abdominal cavity: Obstruction of the proximal AKI, most likely iatrogenic in nature.

Under endotracheal anesthesia, relaparotomy was performed. Subhepatic space is freed. An audit of the subhepatic space revealed a gaping gap of the right and left hepatic lobar ducts at the confluence level. The distal stump of the common hepatic duct is located in the retroduodenal zone. From both ducts comes light transparent bile. Diastasis more than 3 cm.

Perforated PVC tubes with fixation to the duct walls were introduced into both lobar ducts. A loop of the small intestine 80 cm long from the Terets ligament is brought to the liver gate in front of the transverse colon. In the transverse direction, the intestine is dissected up to 1.5 cm long with coagulation of the prolapse mucosa. The distal ends of the tubes are wound: the right in the outlet, and the left in the lead loop. Two atraumatic Vicryl needles 4/0 with a single-row continuous continuous precision suture formed a brown-digestive anastomosis according to Brown.

A 3 cm long incision was made on the stomach in close proximity to the lesser curvature. A longitudinal section of an adequate length was made on the adducting loop of the small intestine at a distance of 10 cm from the biliodigestive anastomosis. Formed gastroeyunoanastomosis.

A safety drainage is installed in the subhepatic space.

Control for hemostasis is dry. The wound is sutured in layers.

In the postoperative period, there was a leakage of bile by safety drainage in an insignificant amount, which stopped on the 5th day. Safety drain removed.

A month later, an endoscopic examination was performed through the gastro-union-anastomosis formed during the operation. On the front wall in the region of the angle of the stomach, a wide opening of the gastroenteroanastomosis up to 1.5 cm with the flow of bile is determined. The device is held in the intestine. Two stents are located in the right and left lobar ducts of the liver. Both stents are sequentially removed with a diathermy loop. The area of the hepatopathyunoanastomosis is formed up to 1.5 cm wide. Transparent bile comes from the ducts.

The patient was discharged in satisfactory condition. Biochemical analyzes are within normal limits.

Control endoscopic examination after 2.5 and 6 months - satisfactory condition.

Example 2

Patient X., born in 1938, and / b No. 9856, was admitted to the surgical department with a diagnosis of external bile fistula.

Anamnesis: operated on for stricture of the distal choledochus.

Upon receipt, the condition is satisfactory.

On examination:

Extra-drainage fistulography: the right and left intrahepatic lobar ducts are contrasted through the Keru drainage; contrast is not detected in the lumen of the duodenum.

Under endotracheal anesthesia, relaparotomy was performed. Subhepatic space is freed. During the audit, in the middle third of the common bile duct, the previously established Kera drainage is determined.

Intraoperative cholangiography - unexpanded intrahepatic ducts of both lobes were performed, the flow of contrast into the intestinal lumen was not determined. The small intestine is disabled according to Ru. By the above method, a biliodigestive anastomosis was formed on the drainage. At a distance of 8 cm from the biliodigestive anastomosis, a gastrojejunoanastomosis with the blind end of the intestine disconnected along the Ru is formed. In this case, the incision in the stomach 3 cm long was made in close proximity to the lesser curvature.

A safety drainage is installed in the subhepatic space.

Control for hemostasis is dry. The wound is sutured in layers.

The postoperative period was uneventful.

The patient was discharged in satisfactory condition. Biochemical analyzes are within normal limits.

Recommendations are given: Control endoscopic examination after 2.5 months.

Our observations show that the use of endoscopic correction of OBD through gastroenteroanastomosis is a simple, affordable and safe method. Manipulation can be carried out by an endoscopic surgeon under local anesthesia. If necessary, multiple repetitions of manipulations are possible.

The proposed method allows to reduce the morbidity of medical interventions in the postoperative period, has a good cosmetic effect, improves the comfort of a patient's life. The method allows for endoscopic correction of biliodigestive anastomoses in an affordable and easily feasible way.

Claims (1)

A method for treating diseases and traumatic injuries of the extrahepatic bile ducts, including applying a biliodigestive anastomosis, disabling a portion of the small intestine, draining the bile ducts, characterized in that they apply a biliodigestive anastomosis on internal frame drains / stents on a loop disconnected along the Roux or on a long loop with Brain anastomosis after which a gastrojunoanastomosis with a blind end disconnected according to Ru or with a discharge loop disconnected according to Brown of the small intestine is applied, with an incision in the stomach e is produced in the transverse direction in the middle third of the stomach in close proximity to the lesser curvature 3-4 cm long, and an incision is made in the small intestine of an adequate length in the longitudinal direction at a distance of 8-10 cm from the superimposed biliodigestive anastomosis, while the distal ends of the drains are left in the lumen of the small intestine or is removed through the opening of the gastroejunoanastomosis into the cavity of the stomach.