RU2530668C1 - Method for pancreaticoduodenal resection in locally advanced cancer in periampullary region with tumoural invasion of portal vein - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: circular en bloc resection of the portal vein with a pancreaticoduodenal complex is followed by its autovenous prosthetic repair. The autovenous graft preliminarily resected is presented by the left renal vein. Both conduit ends are anastomosed with the portal vein stumps. The left renal vein stump is sutured end-to-end together with the lower mesenteric vein stump.

EFFECT: method enables performing the adequate repair of the mesenteric-portal veins after extensive resection with recovering the mesenteric-portal and renal blood flow as close to the physiological one as possible, reducing hospital mortality and postoperative complications.

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Description

The present invention relates to medicine, namely to surgery, and can be used for surgical treatment of locally advanced cancer of the periampicular region with tumor invasion of the portal vein.

Malignant formations of the periampicular region due to the high frequency of local spread of the tumor are characterized by very low resectability - about 16-20%. This is largely due to the relatively late onset of symptoms, the meager manifestation on the part of laboratory parameters and the difficulty in diagnostic interpretation of the initial changes in the head of the pancreas. At the same time, despite the improvement of modern diagnostic methods for visualizing focal lesions, immunological and genetic screening methods, the frequency of locally advanced cancer of this localization reaches 47.6%.

Radical operations in locally advanced cancer of the periampicular region with invasion of the main veins of the mesentericoportal system are extremely rare and only in few clinics. The limitations in the operation are largely due to the lack of effective technologies for resection and reconstruction of the main veins, taking into account the high variability of their tumor lesions. These circumstances largely determine the relevance of the development of surgical technologies for advanced pancreatoduodenal resection in locally advanced periampicular cancer with extensive tumor invasion of the portal vein.

There is a method of reconstruction of the portal vein after its resection in case of its tumor invasion when performing pancreatoduodenal resection, which is carried out as follows: for tumor invasion of the portal vein at the level of splenic and superior mesenteric vein infusion into it, the splenic vein is ligated (without splenectomy) in combination with proximal and distal resection of the affected portal vein segment, and reconstruction is carried out due to an autovenous graft from the iliac vein (Yu.A. Nesterenko, A. V. Prikazchikov, Current Trends in Surgical Treatment of Pancreatic Cancer Patients // Annals of Surgical Hepatology, vol. 4. - No. 2 - 1999. - P.13-22).

The method has the following disadvantages:

a) ligation of the splenic vein leads to a reduction in portal blood flow by at least 50%, which leads to the development of ischemia of the hepatic parenchyma, hepatic cell failure;

b) ligation of the splenic vein leads to a decrease in linear and volume velocity in the portal system, which entails venous thrombosis in the anastomotic zone;

c) sampling of an autovenous conduit from the iliac vein significantly increases the duration and invasiveness of the operation, the size of the operative blood loss, requires the expansion of surgical access and mandatory reconstruction of the iliac vein, is accompanied by the risk of severe thrombotic complications in this venous pool (ileofemoral thrombosis, lower vena cava syndrome, pulmonary embolism );

d) when using an iliac vein graft, the problem of the mismatch between the diameters of the conduit and the stumps of the resected veins often arises.

Closest to the technical nature of the proposed method there is a method for reconstruction of the portal vein after its resection in case of tumor invasion when performing pancreatoduodenal resection, which is performed as follows: after removal of the tumor together with the confluence of the superior mesenteric and splenic veins as a single unit, the reconstruction of the superior mesenteric and portal is performed veins using an autovenous insert from the left renal vein under the control of the diameter of the lumen and subsequent stitching into the transplant splenic vein. Several patients in the postoperative period showed an increase in serum creatinine to 133 μmol / L (1.5 mg / dl), which indicated the occurrence of renal failure (Rory L. Smoot, John D. Christein, Michael B. Famell An Innovative Option for Venous Reconstruction After Pancreaticoduodenectomy: the Left Renal Vein // J. Gastrointest. Surg. - 2007. - N. 11 - P. 425-431).

But the method has the following disadvantages:

- the use of this method entails a risk of developing acute renal failure due to impaired venous outflow from the left kidney and is not feasible in patients with acute or chronic renal pathology.

The technical result of the proposed method of pancreatoduodenal resection in locally advanced cancer of the periampicular region is an adequate reconstruction of the veins of the mesenteric-portal system after extensive resection, the ability to restore the mesenteric-portal blood flow as close to physiological as possible, to eliminate the risk of complications resulting from the use of autovenous conduits.

The specified technical result is achieved by the fact that after circular resection of the portal vein as a single unit with the pancreatoduodenal complex, its autogenous prosthetics is performed, and the left renal vein is used as an autovenous graft, which is resected at the site of its entry into the inferior vena cava from one side and at the site of the left left site. the adrenal and ovarian (testicular) veins, on the other hand, form an autovenous conduit and both ends of the conduit anastomose with stumps of the portal vein, the stump of the left renal vein nastomoziruyut to the proximal stump of the inferior mesenteric vein type end-to-end.

The method is illustrated by figures 1-2 applications, where 1 is the superior mesenteric vein; 2 - portal vein; 3 - splenic vein; 4 - resected pancreas; 5 - the left renal vein; 6 - the left adrenal vein; 7 - ovarian (testicular) vein; 8 - inferior mesenteric vein; 9 - anastomosis between the left renal vein and inferior mesenteric vein; 10 - anastomosis between conduit and portal vein.

Method description

The method is as follows. An extended total median laparotomy with hardware access correction is performed. In the process of traditional mobilization of the pancreatoduodenal complex, an intraoperative study is performed, during which the size and location of the tumor, the presence and extent of tumor invasion of the main veins of the mesenteric-portal system and their individual anatomical features are clarified. After that, in the absence of extensive tumor invasion of the terminal sections of the superior mesenteric (1), splenic (3), initial portal vein (2) and the portal vein formation site, a single block with the pancreatoduodenal complex of the portal vein is resected under complete compression (figure) one). After this, a section of the left renal vein between its inflow into the inferior vena cava and the place where the left adrenal and left ovarian (testicular) veins fall into it, an autovenous prosthesis is made. Veins are taken according to one of the generally accepted methods. Further, both ends of the conduit anastomose with stumps of the portal vein (10). After the resumption of portal blood flow, the inferior mesenteric vein is resected, the distal stump is ligated, and the proximal stump is anastomosed with the stump of the left renal vein (9) (Fig. 2).

After this, the digestive tract is reconstructed using one of the available methods with the formation of pancreato-entero, gastro-entero and choledocho-enteroanastomoses.

The possibility of practical use of the proposed method is illustrated by an example of its implementation in clinical practice.

Example 1. Patient U., 58 years old, was admitted to the hospital with a diagnosis of

locally advanced cancer of the head of the pancreas with invasion of the main veins of the mesenteric-portal system. According to instrumental examination, data for the presence of distant metastases were not received. After preoperative preparation, the patient underwent an operation: expanded pyloric preserving pancreatoduodenal resection, resection of the portal vein as a unit with a tumor, lymphadenectomy. A section of the left renal vein was resected at the place of its inflow into the inferior vena cava and at the place of the left adrenal and left ovarian vein inflow into it, an autovenous prosthesis was made, after which both its ends were anastomosed with stumps of the portal vein. After the resumption of portal blood flow, a resection of the inferior mesenteric vein was performed, the distal stump of which was bandaged, an anastomosis was formed between the proximal stump of the inferior mesenteric vein and the left renal vein. Reconstruction of the gastrointestinal tract was carried out by the formation of end-lateral pancreatoenteroanastomosis, gastroenteroanastomosis, end-to-side choledocho-enteroanastomosis and end-to-side enteroanastamosis. The postoperative period was uneventful. The patient was discharged from the hospital in a relatively satisfactory condition on the 16th day after the operation. After the operation, the patient was repeatedly examined. 3 years after the operation, the condition is satisfactory, no data for the recurrence of the disease were found, patency of the veins of the mesenteric portal system and the left renal vein was satisfactory, and renal failure was not detected.

The proposed method of pancreatoduodenal resection in locally advanced cancer of the periampicular region with tumor invasion of the portal vein has been used in 10 patients with locally advanced pancreatic cancer. At the same time, all patients underwent extended pyloropreserving pancreatoduodenal resection. There was no hospital mortality. No postoperative complications were observed. There were no thrombotic complications in this group of patients. Renal failure was not detected. Diuresis in all patients remained adequate to the water load. No increase in serum creatinine was observed. Venous hypertension was not detected in the mesenteric-portal system and the left renal vein system.

Thus, the application of the proposed method allows you to perform a radical operation in patients with locally advanced periampicular pancreatic cancer with extensive invasion of the portal vein, to carry out an adequate and most physiological reconstruction of the resected vessels.

Socio-economic importance. The developed method can significantly improve the operability and long-term survival of patients with locally advanced periampicular cancer, improve the immediate and long-term results of radical surgical treatment of periampicular tumors with extensive invasion of the portal vein.

Claims (1)

The method of pancreatoduodenal resection in case of locally advanced cancer of the periampicular region with tumor invasion of the portal vein, including circular resection of the portal vein as a single unit with pancreatoduodenal complex, followed by its autovenous prosthetics and reconstruction of the digestive tract, characterized in that the transplant is used for autogenous transplantation are resected, and both ends of the conduit anastomose with the stumps of the portal vein, the stump of the left renal veins are sutured to the stump of the inferior mesenteric vein end-to-end.

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