RU2479270C1 - Pancreaticojejunostomy technique in subtotal pancreatic head resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and may be applicable for pancreaticojejunostomy in subtotal pancreatic head resection. A Roux-opened defunctioned oral end of a small intestinal loop is longitudinally dissected along an antimesenteric edge to make a small intestinal lumen matched with a diameter of the cavity formed after the pancreatic head resection. The lumen of the dissected intestine and the anastomosed pancreatic cavity are mated by a single-layer continuous double suture each of which is brought out over the edge of the anastomosed pancreatic cavity and small intestinal wall in the serous-muscle-submucosal direction from the oral end on one side to the end of its dissection line in the distal direction thereby forming consistently lower and upper lip of the anastomosis, and then the adjoining ends of the sutures are tightened together.

EFFECT: method provides a functionally advantageous internal drainage of the pancreatic duct system with a minimum of running sutures.

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Description

The invention relates to medicine, and more specifically to surgery of the pancreas, and is intended to perform anastomoses of the pancreas with the small intestine with subtotal resection of the pancreatic head for chronic pancreatitis.

A known method of surgical treatment of chronic pancreatitis, including duodenum-preserving resection of the pancreatic head according to Beger (HGBeger, M. Buchler, R. Bittner Duodenum - preserving Resection of the Head of the Pancreas - an Alternative to Whipples Procedure in Chronic Pancreatins. Hepato- Gastroenterol. 1990, 37, p. 283). This method is used for the surgical treatment of chronic pancreatitis with a primary lesion of the head. In this case, the body of the pancreas intersects at the level of the isthmus with separation of the latter from the fusion with the superior mesenteric and portal veins. Then, the pancreatic head is separated from the portal vein in the direction of the common bile duct while maintaining 5-8 mm of pancreatic tissue along the wall of the duodenum to maintain its blood supply. The reconstructive stage consists in the formation of pancreaticenteroanastomosis with double-row interrupted sutures “end to side” with the body and “side to side” with the remaining part of the pancreatic head and a loop of the small intestine isolated according to Ru.

The disadvantage of this variant of the operation is its technical complexity, the performance of two anastomoses, which increases the risk of postoperative complications.

There is also known a method of pancreatojejunostomy for subtotal resection of the pancreatic head, which includes a resection step with the left rim of the pancreas along the duodenum and the formation of a cavity for subsequent anastomosis (RU 2421158 C1, 06/20/2011).

The main disadvantage of this method is the creation of external drainage of the ductal system of the pancreas by introducing thick silicone drainage into the main pancreatic duct and the formation of an “omentum sac” drained outward, which should lead in some cases to the development of an external pancreatic fistula, an increase in the duration of treatment and repeated surgical interventions .

The following disadvantages of the above method are the peritonization of the “drowned out” stump of the small intestine and the execution of additional sutures on it to fix the silicone tube, which complicates the operation technique, lengthens it and increases the risk of postoperative complications.

Similarly, a drawback is the implementation of additional sutures when fixing the free strand of the greater omentum to the outer edge of the resected pancreatic head, which also complicates the operation and reduces the hermeticity of the performed anastomosis.

The completion of the operation of the prototype method by drainage of the abdominal cavity and the formation of a suspended enterostomy, as well as the removal of a pancreatic head and tail virsungostoma on the skin lengthens the treatment time and reduces the quality of life of patients in case of formation of an external pancreatic fistula.

The technical result of the invention is to minimize the number of sutures performed by creating adequate internal drainage of the pancreatic ductal system “end to end” with simplification of the technique, reducing the time of surgery and reducing injuries and the risk of complications associated with insufficient sealing of the anastomosis.

The specified technical result is achieved by the fact that in the pancreatojejunostomy method for subtotal resection of the pancreatic head, which includes a resection step with leaving the rim of the pancreas along the duodenum and the formation of a cavity for subsequent anastomosis, according to the invention, the non-muffled oral end of the thin loop of the loop dissected longitudinally along the mesenteric margin to achieve compliance of the lumen of the small intestine with the diameter of the cavity obtained after resection of the pancreatic head, then the lumen of the dissected intestine and the anastomotic cavity of the pancreas are combined in a single row continuous suture with two threads, each of which is passed through the edge of the anastomosed cavity of the pancreas and the wall of the small intestine of the serous-muscular-submucosa from the oral end from one side to the end of the dissection its lines in the distal direction, forming successively the lower and upper lip of the anastomosis, after which the adjacent ends of the opposite threads are connected between the battle.

The proposed method is illustrated by drawings, where figure 1 shows a view of the performed lower lip of pancreaticostomy; figure 2 is a completed view of pancreatojejunostomy.

Designations adopted in the figures:

1 - dissection line of the oral end of the loop of the small intestine along the mesenteric edge,

2 - cavity after resection of the head of the pancreas for anastomosis with the small intestine,

3 - continuous thread performed lower lip of the anastomosis,

4 - opposite ends of both threads of the anastomosis before tying.

The method is as follows.

Cicatricial parenchyma of the pancreatic head is excised with a posterior parenchymal capsular plate 3-5 mm thick (2) and a rim of pancreatic tissue 3-5 mm along the duodenum. In this case, an opened lumen of the main pancreatic duct is found. If necessary, the terminal section of the common bile duct is opened, anastomosing its lumen with the posterior parenchymal-capsular plate formed after resection of the pancreatic head cavity. Then perform the audit of the main pancreatic duct in the distal direction in order to clarify its patency, to eliminate the presence of strictures and intraductal calculi.

Next, they decide on the choice of the method of the recovery phase of the operation. An indispensable condition for the developed method is the abandonment of the parenchymal-capsular plate of the posterior pancreatic wall, which is used as a framework limiting the cavity for anastomosis with the small intestine, as well as the presence of patency and the absence of strictures of the main pancreatic duct in the distal pancreas.

The loop of the small intestine is mobilized according to Ru, while the oral end of the intestine is not muffled. To match the diameter of the anastomosed cavity obtained after resection of the pancreatic head and the lumen of the small intestine, the oral end of the loop of the small intestine is additionally longitudinally dissected along the mesenteric edge (1).

Directly terminological pancreatojejunostomy is performed by combining a single-row continuous suture with two non-absorbable sutures, each of which is passed through the edge of the anastomosed cavity of the pancreas and the wall of the small intestine of the serous-muscular-submucous membrane from the oral end to the site of its dissection in the distal direction (first forming 3 lower) and then the upper lip of the anastomosis, after which the adjacent ends of the opposite threads are pulled with a metered force to seal with receiving tissue and link (4). At the same time, the dense, fibro-altered pancreatic tissue does not allow the anastomosis to corrugate. Used thread - "Prolen 3.0"

Clinical example

Patient Sh., 59 years old, was operated on in one of the city’s clinics with suspected pancreatic head cancer in the scope of diagnostic laparotomy and puncture biopsy. With a puncture under pressure, pancreatic juice was released, subsequently an external pancreatic fistula was formed, which closed independently after a month. The histological conclusion: Chronic pancreatitis. The patient is consulted by an oncologist, the diagnosis of cancer is rejected. The patient was admitted to the design bureau 3 months after the first operation with complaints of persistent pain in the mesogastric region and the presence of periodically loose stool. Diagnosed with Chronic calculous pancreatitis with isolated lesion of the pancreatic head. This diagnosis was confirmed by MSCT data: there was an increase in the head of the pancreas up to 5-6 cm, pronounced intraductal hypertension with expansion and undisturbed patency of the main pancreatic duct. The diameter of the latter was 13-14 mm in the absence of strictures and calculi in its lumen.

10/18/11. an operation was performed - subtotal resection of the pancreatic head in the Bernese version of Beger’s operation with a single-row terminological pancreatojejunostomy. The resection step was performed according to the known method, the diameter of the cavity after resection of the pancreatic head was about 4-4.5 cm. To achieve compliance with the lumen of the small intestine to the diameter of the cavity obtained after resection of the head of the pancreas, a longitudinal dissection of the non-muffled oral end of the loop of the small intestine along the mesenteric to the edge. Next, the lower lip of the anastomosis was made with a single-row continuous suture with non-absorbable suture thread “Prolen-3.0”. After making sure that the longitudinal section of the non-muffled end of the small intestine is sufficient to combine its lumen with the anastomosed cavity of the resected pancreatic head, the upper lip of the anastomosis is started. The upper lip of the terminological pancreatojejunostomy is made using the second non-absorbable suture "Prolen-3.0" also in a single row. The wall of the small intestine during anastomosis was captured by serous-muscular-submucosa. As a result, the anastomosis was performed with just two threads. In the end, the adjacent ends of the opposite threads were interconnected, without requiring additional peritonization. The duration of the operation is 2 hours 40 minutes. Blood loss - 200 ml. The operation was completed by staging 2 control PVC tubes, which were removed on the 2nd and 3rd day. On the 16th day after surgery, the patient was discharged. Wound healing - primary intention.

The proposed method allows to eliminate intraductal hypertension in chronic pancreatitis, to provide a functionally advantageous internal drainage of the pancreatic ductal system by creating an end-to-end anastomosis with a minimal number of sutures, to increase and reduce the risk of anastomosis failure, simplify the technique and reduce the time of surgery.

Claims (1)

The method of pancreatojejunostomy in case of subtotal resection of the pancreatic head, which includes the resection step with leaving the rim of the pancreas along the duodenum and the formation of a cavity for subsequent anastomosis, characterized in that the non-muffled oral end of the loop of the small intestine cut off along the Roux to cut longitudinally along the margin the lumen of the small intestine to the diameter of the cavity obtained after resection of the pancreatic head, then the lumen is dissected of the intestine and anastomosed pancreatic cavity are combined with a single row continuous suture with two threads, each of which is passed through the edge of the anastomosed pancreatic cavity and the wall of the small intestine of the serous-muscular-submucosa from the oral end on one side to the end of the dissecting line in the distal direction, forming sequentially the lower and upper lip of the anastomosis, after which the adjacent ends of the opposite threads are connected.

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