RU2549484C1 - Method for sealing pancreato-intestinal anastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: local resection of head and body of pancreas is followed by forming first posterior and then anterior lips of the pancreato-intestinal anastomosis. That is followed by long pancreatoenterostomy at 15 cm from a stump border of Roux-defunctioned enteric loop. A free end of the distal portion of the Roux-defunctioned enteric loop is turned towards the anterior or posterior anastomosis lips. The enteric loop - pancreatic tissue and the enteric loop - enteric tissue are sutured together in zigzag order. The anterior or posterior anastomosis lips are sealed within a fistula.

EFFECT: method provides the more effective sealing of the pancreato-intestinal anastomosis sutures following pancreatectomy and prevents complications by involving the free end of the Roux-defunctioned enteric loop.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used to prevent postoperative complications.

Pancreatic disease has a distinct upward trend, and this applies not only to pancreatic tumors, but also to chronic pancreatitis. When a pancreatic-intestinal anastomosis is applied, which completes the resection of the pancreas, the likelihood of complications is high, this is due to the production of enzymes, as well as the morphological structure of the pancreatic tissue. Most often there is a cutting of sutures on the pancreatic tissue or their melting. The problem of improving and sealing the pancreatic-intestinal anastomosis seems relevant.

A known method of sealing pancreatic-intestinal anastomosis by applying pancreaticunoanastomosis isoperistaltically, so that the sutured blind end of the intestinal loop is directed towards the tail of the gland and adjoins it. Anastomosis is formed by interrupted sutures. When the anastomosis is formed by double-row interrupted sutures, the first posterior row of interrupted sutures captures the serous-muscular membrane of the intestine and pancreatic tissue together with its peritoneal cover. Having imposed the back row of sutures of pancreatojejunoanastomosis, they cut the intestine longitudinally along the length corresponding to the length of the gland incision. The second row of posterior nodal sutures is passed through all layers of the jejunum and the edge of the dissected gland, not trying to capture the mucous membrane of the duct into the suture (this is permissible only with cystic expansion of the duct). Further, observing the technical specifications described, two rows of interrupted sutures are placed on the anterior lip of the anastomosis (Danilov M.V., Fedorov V.D. Pancreatic Surgery: A Guide for Doctors. - M .: Medicine, 1995. 512 p: p: 310 -322).

However, the known method is ineffective, since when a double-row suture is applied between the intestine and the resected pancreas, a deficiency of the intestinal wall often occurs. This occurs in cases where an intraparenchymal resection is performed with the edges of the resected pancreas diverging, or in cases when the intestine is small in diameter, then the second row of sutures is applied with tension of the tissues, which subsequently leads to eruption of the suture.

The closest technical result achieved (prototype) is a method for sealing pancreatic-intestinal anastomosis, which consists in local resection of the pancreatic head with lateral pancreaticoejunostomy or longitudinal pancreatoenterostomy with intraparenchymal resection. Enter the abdominal cavity through either the upper median laparotomy or through bilateral hypochondrium. Examine the organs of the abdominal cavity to exclude another pathology. The omentum is separated from the transverse colon and reclined upward.

First, the tissue of the gland is dissected before the duct. The volume of excision of the head of the pancreas is progressively increased, starting along the open proximal part of the pancreatic duct. Most of the pancreatic head can be excised to the level of the duct of the gland. The fact that the superior mesenteric and portal veins were found before this stage allows the surgeon to perform a head resection without fear of injury to these venous structures.

A branch of a U-shaped small intestinal anastomosis along the Ru 60 cm long is created. It is carried out through an opening in the mesentery of the transverse colon and a pancreaticoduodenoanastomosis is applied with it “side to side”. First create the lower back wall of the anastomosis with many single Lambert sutures with silk No. 3/0. Then create an internal continuous twisted sealing seam with absorbable synthetic thread No. 3/0, continuing along the front wall of the anastomosis according to the Connell method.

The front wall is closed with a continuous single-row suture with an atraumatic thread No. 3. If the pancreatic duct is slightly expanded, the anastomosis can be performed with one row of single sutures with silk No. 3/0, the nodes of which are tied outside.

Two pancreatic silicone plastic drains connected to a closed aspiration system are brought to the pancreaticojejunoanastomosis. From the abdominal cavity, drainage is removed through puncture wounds in the upper left quadrant of the abdominal wall. The branch of the U-shaped anastomosis according to Ru is fixed to the edges of the opening in the mesentery of the transverse colon (Atlas of operative gastroenterology / John L. Cameron, Korin Sandon; translated from English. Edited by A.S. Ermolov. - M.: GEOTAR-Media, 2009. - 560 p. P. 277-283).

However, the known method is ineffective and has drawbacks, first of all, this concerns injection into the pancreatic tissue, if the glandular tissue is loose, then thread cutting can be expected due to the release of its enzymes and inflammation. A single-row suture in some cases becomes leaky due to an inflammatory process in the pancreatic tissue, and in cases of concomitant chronic pancreatitis of the cystic accumulation or abscess along the upper edge of the gland, the risk of pancreatic-intestinal anastomosis failure increases.

The technical result of the proposed method is to increase the effectiveness of sealing pancreatic-intestinal anastomosis after resection of the pancreas.

The technical result is achieved by isolating the intestinal loop with a length of at least 60 cm and dissecting it for the application of pancreato-intestinal anastomosis, departing 15 cm from the edge of the stump of the small intestine with the formation of the first posterior and then the front lip of the pancreatic-intestinal anastomosis, followed by a turn of the free end into the area of the anterior or posterior lip of the anastomosis and its sealing by suturing the intestinal loop - tissue of the pancreas and the intestinal loop - tissue of the small intestine in a checkerboard pattern.

The authors proposed a method for sealing pancreatic-intestinal anastomosis by applying the free end, turned off along the Ru intestinal loop, which allows for the prevention of suture failure.

The method is as follows.

The method is illustrated by figures 1 and 2.

The figure 1 shows the image of the mobilized intestinal loop according to Ru.

The figure 2 presents the final view of the proposed method.

An upper-median laparotomy is performed, Segal retractors are installed. After revision of the abdominal organs, release from possible adhesions and adhesions, access is via a small omentum, the peritoneum is dissected. The pancreas is mobilized. A puncture of the main pancreatic duct is performed. The changed pancreatic tissue is excised.

Departing from the Treits ligament 30-40 cm, an intestinal loop of at least 60-80 cm long is mobilized and turned off along Ru. The loop is moved into the gland bag through the window in the mesocolon mesentery.

Fixing sutures of the first row are applied between the intestinal loop and the capsule of the pancreas, after which the intestinal loop is opened for the length necessary for the imposition of the anastomosis, retreating 15 cm from the muffled end of the intestinal loop. A continuous suture is used between the pancreatic tissue and the dissected intestinal wall using atraumatic material.

After that, the free end of the distal part of the loop behind the anastomosis is deployed into the anastomosis zone and the anterior lip, and, if necessary, the anastomotic posterior lip is sealed by single stitches between the free end of the intestinal loop and the rest of the capsule and the anastomosed intestinal loop in a checkerboard pattern.

In complicated cases, when along the upper edge of the pancreas the tissues are infiltrated or are the bottom of the opening cyst or abscess, the application of 2 rows of sutures is advisable.

Since the diameter of the intestinal loop for 2 rows of sutures is insufficient to apply them without tension, therefore, for this purpose, additional plastic material is needed, which serves as the free end of the intestinal loop.

Due to the rotation of the loop, its free end is used as a plastic material for sealing anastomosis 2 with a number of sutures.

The inventive method treated 3 patients. The inventive method allows to prevent the occurrence of insolvency of pancreatic-intestinal anastomosis in the early postoperative period and can be used for resection of the pancreas, in complicated cases with a cyst or abscess.

Clinical example

Patient Ch., 46 years old, was admitted to the hospital with complaints of pain in the epigastrium. He considers himself sick since 2000, when he was first diagnosed with chronic pancreatitis. Since July 2013, it has been deteriorating: the pain intensified, radiating to the left thoracic region, back. Examined by a surgeon AKKP, hospitalized for surgical treatment.

With an objective examination

General condition is satisfactory. The consciousness is clear, the position is active. The physique is correct, moderate in nutrition. The skin is of normal color. Visible mucous membranes are not changed. Peripheral lymph nodes are not enlarged. No swelling. The chest is of the correct form, both halves symmetrically participate in the act of breathing. Percussion is clear pulmonary sound over all pulmonary fields, with auscultation, vesicular breathing, no wheezing. NPV 16 per minute. Heart sounds are muffled, the rhythm is correct. The pulse is rhythmic, good filling 60 per min. HELL - 120/80 mm Hg The area of the bladder and kidneys without deformation, hyperemia, no swelling. The kidneys are not palpable. The symptom of striking is negative on both sides. Status localis: Tongue is wet, not coated. The abdomen is symmetrical, not swollen, participates in the act of breathing. On palpation, mild, moderate soreness in the epigastrium. The liver does not protrude from the edge of the costal arch. The spleen is not palpable. There are no symptoms of peritoneal irritation. The chair is normal. The lumbar region is not swollen, symmetrical. Palpation is painless. The symptom of striking is negative on both sides. Per rectum: Perianal region without features. The sphincter tone is preserved, the wall of the rectum is smooth soft. Gloved without pathological impurities.

Ultrasound of the abdominal cavity 09/03/2013 - the pancreas is medium in size. Contours are fuzzy. The echostructure is heterogeneous due to multiple hyperechoic inclusions from 1.5 to 5 mm with acoustics. Wirsung duct expanded to 14.5 mm, sigmatic branches up to 4.5 mm. In the lumen of the ducts, the hyperechoic inclusions max up to 9 mm are located. MSCT of the abdominal cavity with contrast 09/30/2013: The pancreas is enlarged (34 × 30 × 27). The contours are fuzzy, the structure is heterogeneous due to multiple hyperdensity inclusions with a maximum size of up to 20 mm and hypodense sections. Wirsung duct expanded to 12.3 mm. In the surrounding parapancreatic fiber - hypo-isodens content up to 20 mm wide. In the left subphrenic space, in the region of the tail of the pancreas, between the stomach and spleen, a limited hypodense content is determined, 82x28 mm in size. FGDS 09/11/2013: Chronic gastrobulbit. Insufficiency of cardia function with the phenomena of chronic distal esophagitis. Biopsy No. 12426 - Chronic gastritis with moderate activity, mild atrophy. HP - Neg.

On 08.10.13, after preliminary preoperative preparation, an operation was performed: intraparenchymal resection of the pancreas. Pancreatoenteroanastomosis on the intestinal loop turned off along Ru with sealing of the anastomosis by the free end of the intestinal loop.

During the operation, the iron was enlarged, its walls were infiltrated, the Wirsung duct was punctured, juice was obtained, 3 × 5 cm parapancreatic tissues with turbid contents were obtained, intraparenchymal resection was performed with the duct opening and excision of fibrosed tissues of the body and head of the pancreas. Histological diagnosis: chronic pancreatitis. The intestinal loop was cut out and the pancreato-intestinal anastamosis was applied according to the above technology. The postoperative period was uneventful. The pain disappeared on the 5th day, began to eat, the passage through the intestines recovered.

DG No. 12426 from 09/11/13: chronic gastritis with moderate activity, mild atrophy of HP (-)

OAK of 10.19.12: Er 3.7 × 1012 / L; platelets 486 × 109 / l; HB 126 g / l; L 7.0 × 109 / L.

Biochemical analysis of blood from 10/19/12: amylase 67 U / L; total protein 63.2 g / l.

Discharged with recovery. Control examination after 3 months. There are no complaints at the time of the inspection. The condition is satisfactory. Keeps a diet. He works as a driver.

Thus, the inventive method is highly effective and avoids the failure of the sutures of the pancreatic-intestinal anastomosis and can be used in the complicated course of chronic pancreatitis.

Claims (1)

A method of sealing a pancreatic-intestinal anastomosis, which consists in local resection of the head and body of the pancreas with longitudinal pancreatoenterostomy with intraparenchymal resection of the pancreas, characterized in that they isolate the intestinal loop at least 60 cm long with its dissection for applying pancreato-intestinal anastomosis, from the edge of the stump of the small intestine with the formation of the first posterior and then the anterior lip of the pancreatic-intestinal anastomosis, followed by a turn of the free end into the anterior or posterior region her lips anastomosis and its sealing by suturing the intestinal loop - tissue of the pancreas and the intestinal loop - tissue of the small intestine in a checkerboard pattern.

Images