RU2612806C1 - Method for surgical treatment of chronic pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: artificial passage is created in the pancreas head, in the duct obliteration area. The preserved part of the main pancreatic duct is connected to the duodenum. Duct and created passage stenting is performed to maintain a constant drain.

EFFECT: method of surgical treatment of chronic pancreatitis complicated by pancreatic hypertension, restores the outflow of pancreatic ductal system by creating an artificial passage in the gland head.

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Description

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of patients with chronic pancreatitis complicated by pancreatic hypertension, including in the presence of severe exacerbation.

Chronic pancreatitis (CP) is an inflammatory and degenerative disease that is characterized by progressive proliferation of fibrous tissue, leading to blockage of the ductal system of the pancreas, atrophy of the glandular parenchyma and, as a consequence of this process, to severe exo- and endocrine insufficiency.

The course of the disease is long, recurring. Growing fibro-degenerative changes are irreversible. In the clinical picture, persistent pain syndrome and nutritional disorders are leading.

These changes lead to reduced working capacity, disability of patients with CP (Danilov M.V., Fedorov V.D. Pancreas surgery: A guide for doctors. - M .: Medicine, 1995, 512 p., P. 9 [1]; Kubyshkin V.A., Kozlov I.A., Dolgatov KD Surgical treatment of chronic pancreatitis with a primary lesion of the pancreatic head // Surgery. - 2006 - No. 5 - p. 57-62 [2]; VA Kubyshkin , Kozlov I.A., Krieger A.G., Zhao A.V. Surgical treatment of chronic pancreatitis and its complications. Annals of surgical hepatology. 2012; p. 24-35 [3]) and in the absence tvii adequate surgical care to death.

Chronic pancreatitis and its complications in 50-80% of cases develop in young and mature people, which gives the problem of its treatment social significance due to long periods of temporary disability (see the above links to [1]; [2], as well as Shalimov A.A. et al. Chronic pancreatitis. - Kiev: Zdorovya, 2000; 256 [4]; Ake A. Chronic pancreatitis. N Am J Med Sci. 2011 Aug; 3 (8): 355-357 [5 ]).

The incidence of CP over the past 25 years has increased 18 times and its share in the structure of digestive diseases has reached 8-10% (see [1], [2], as well as Buchler MW, Martignoni M.E., Friess N., Malfertheiner P. A proposal for a new clinical classification of chronic pancreatitis. BMC Gastroenterol. 2009; 9 (1): 93-100 [6]; Goh KL Chronic pancreatitis: aetiology, epidemiology and clinical presentation. Med J Malaysia. 2005; 60 ( Suppl B): 94-98 [7]; Spanier BW, Dijkgraaf MG, Bruno MJ Epidemiology, aetiology and outcome of acute and chronic pancreatitis: An update. Best Pract Res Clin Gastroenterol. 2008; 22 (1): 45-63 [ 8]). Mortality from CP complications within 10 years of observation reaches 20.8-35%, and over 20% over 50% (Ammann RW, Mullhaupt B. Do the diagnostic criteria differ between alcoholic and nonalcoholic chronic pancreatitis? J Gastroenterol. 2007; 42 (Suppl 17): 118-126 [9] and the previously mentioned source [6]).

Conservative treatment of CP is ineffective and most often has temporary success [6].

The desire to relieve the patient of the suffering associated with persistent pain syndrome, and the presence of complications that can only be resolved surgically, are indications for surgical treatment.

Surgery used to treat CP can be divided into drainage and resection.

The most common drainage intervention is longitudinal pancreatojejunostomy. This operation is notable for its simplicity of execution, preservation of the parenchyma of the gland, low level of postoperative complications and low mortality. However, with good immediate and immediate results in the long term, relapses of the pain syndrome are frequent, the number of unsatisfactory results increases [3]. Many authors come to the conclusion about the inevitable obliteration of pancreatojejunoanastomosis in more than half of those operated on in the long term.

Dissatisfaction with the long-term results of drainage operations was the basis for the use of resection interventions. For a long time, the main intervention in CP was pancreatoduodenal resection (PDR), which persistently relieves pain. Despite the fact that with the acquisition of experience, the number of postoperative complications was significantly reduced, the main drawback of this operation is the removal of the duodenum, which negatively affects the entire digestion process, as well as the frequent development of diabetes mellitus. The pyloropreserving version of Whippla's surgery allowed to slightly improve the results of treatment, but did not radically change the situation.

Currently, pancreatoduodenal resection in any of the modifications (in the classic version or with the preservation of the pylorus) cannot be considered indicated for CP due to the excessive amount of intervention and a gross disturbance in the physiology of digestion. In addition, the removal of most of the pancreatic parenchyma inevitably leads to the development of insulin-dependent diabetes mellitus in most patients with CP. According to various authors, its frequency ranges from 26 to 45%.

, Bittner R. et al. Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis: early and late results. Ann Surg. 1999; 209: 273-278 [10]; Beger H.G., Schlosser W., Friess H.M., Buchler M.W. Duodenumpreserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience. Ann Surg 1999; 230: 512-519 [11]; Buchler M.W., Friess H., Uhl W., Malfertheiner P. Chronic Pancreatitis. Novel Concepts in Biology and Therapy. Blackwell Science, Berlin 2002 [12]; Friess H., Kleeff J., Buchler M.W. Molecular pathophysiology of chronic pancreatitis-an update. J Gastrointest Surg. 2003; 7(8): 943-945 [13]).In addition to pancreatic hypertension, the modern concept of the etiology of pain syndrome in CP considers direct damage to nerve fibers, perineural infiltration, edema and swelling of the myelin sheath of pancreatic nerves and the associated increased expression of neurotransmitters such as substance P and calcitonin gene related peptide, which are important for pain (Beger HG,

, Bittner R. et al. Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis: early and late results. Ann Surg. 1999; 209: 273-278 [10]; Beger HG, Schlosser W., Friess HM, Buchler MW Duodenumpreserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience. Ann Surg 1999; 230: 512-519 [11]; Buchler MW, Friess H., Uhl W., Malfertheiner P. Chronic Pancreatitis. Novel Concepts in Biology and Therapy. Blackwell Science, Berlin 2002 [12]; Friess H., Kleeff J., Buchler MW Molecular pathophysiology of chronic pancreatitis-an update. J Gastrointest Surg. 2003; 7 (8): 943-945 [13]).

This concept served as the basis for the use of a new type of resection interventions for CP, which evolved from classical PDD to an isolated resection of the pancreatic head. Beger and Frey's surgery significantly improved treatment outcomes compared to pancreatoduodenal resection ([10]; Frey CF, Amikura K. Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg. 1994; 220: 492-507 [14]).

An isolated resection of the pancreatic head with preservation of the duodenum, supplemented by pancreatojejunoanastomosis - Beger or Frey operation, are currently considered the most indicated for CP. Technically, these operations are complex and time-consuming. The disadvantage of these operations is the large number of postoperative complications even with material concentration in specialized institutions and the development of diabetes mellitus in 20% of the operated patients (Kriger A.G., Kubyshkin V.A., Karmazanovsky G.G. et al. Postoperative pancreatitis in surgical interventions on Pancreas Surgery, N.I. Pirogov Journal 2012; 4: 14-19 [15]; Kubyshkin V.A., Kriger A.G., Vishnevsky V.A. et al. Extirpation of the distal stump of the pancreas with profuse intra-abdominal arrozionny bleeding uu caused by postoperative pancreatonecrosis Pirogov Surgery Journal 2012; 11:.... 4.7 [16] and [2], [3]).

Dissatisfaction with the results of surgical treatment of CP leads surgeons to look for new methods and modify the already known operations.

A variety of interventions in CP and the lack of a unified approach to the choice of a particular option in the treatment of a particular patient indicate an unresolved problem of surgical treatment of CP.

All interventions that have so far been used by domestic and foreign surgeons have the same “weak link” pancreatoenteroanastomosis, which is the main reason for the unacceptable number of postoperative complications for a planned operation. In addition, the wide anastomosis of the pancreas with the small intestine is not physiological and inevitably triggers the activation mechanisms of enzymes in the anastomosis zone. The increase in exo- and endocrine insufficiency after resection interventions force us to look for new ways in the treatment of CP.

Waysung duct endoscopic stenting methods (Dumonceau JM, Delhaye M., Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2012; 44: 784-796 [17] are also known. ; Weber A, Schneider J, Neu B et al. Endoscopic stent therapy for patients with chronic pancreatitis: results from a prospective follow-up study. Pancreas. 2007; 34: 287-294 [18]; Kim C. H., Bang S. et al. Analysis of the Effects of Stent Insertion and the Factors Related to Stent Retrieval in Chronic Pancreatitis. Gut and Liver, Vol. 1, No. 1, 2007: 63-67 [19]).

This procedure is possible only in a small part of patients who did not have complete obliteration of the ductal system in the head of the gland. This circumstance is the reason for the rare implementation of this procedure and the impossibility of its application in the development of a complete block of the duct system in the head of the pancreas.

The closest technical solution to the claimed method is a method of percutaneous drainage and endoprosthetics of the pancreatic duct in patients with obstruction of the pancreatic duct using a sharpened needle, introducer, bougie of increasing diameter, ultra-rigid conductor, polyethylene catheters of various diameters. After puncture of the pancreas with a needle and the introduction of a conductor into its lumen, an attempt is made to introduce a plastic bougie. In that case, if the density of the pancreatic parenchyma does not allow bougie, then an introducer cannula is inserted through it to the gland. Next, the bougie is replaced with a catheter of the appropriate diameter, the introducer and conductor are removed, the latch and the pavilion are placed on the catheter, the catheter is fixed to the skin. After 1-2 days, the catheter with a guide changes to a larger diameter catheter. If necessary, the simultaneous installation of a larger diameter catheter is performed, the puncture channel is boughened with a bougie of increasing diameter along an extra-rigid conductor. Over the next 5-7 days, bougieurage and replacement of drains of increasing diameter (up to size 12 Fr) are performed. Procedures are performed using an ultra-rigid conductor under fluoroscopic control. Subsequently, the catheter is replaced with a polyurethane endoprosthesis (http://www.cnmt-tula.ru/m111.html[20]).

This method has limited application, in particular percutaneous drainage and endoprosthesis replacement of the pancreatic duct in a number of patients is difficult or impossible to perform due to the fact that the effort required to pass the bougie through the densified pancreatic parenchyma is difficult to control, and such control requires either a very high qualification and extensive experience of the doctor or with excessive force can injure the patient.

As follows from the foregoing, none of the currently used interventions restores the natural physiological mechanism of pancreatic juice into the duodenum, which is necessary for regulating the functioning of the digestive system.

The relief of pain immediately after drainage of the ductal system and the occurrence of pain during obliteration of pancreatojejunoanastomosis in the long term leads to the idea that the idea of drainage itself is correct, but another method of surgical intervention is needed, which would restore the natural path of pancreatic juice into the lumen of the duodenum .

Thus, at present, there is a need to develop new approaches in the surgical treatment of CP, to develop an intervention that reliably relieves the patient of pain that is not accompanied by the development of diabetes, with a minimal risk of complications, simple to implement, accessible to a wide range of surgeons.

The solution to this problem is possible by developing a new type of drainage surgery, the purpose of which is to restore the passage of pancreatic juice from the saved part of the Wirsung duct into the lumen of the duodenum by creating an artificial passage in the head of the gland, the functioning of which will be supported by the stent installed in the artificial passage. We called this operation an open stenting of the pancreatic duct (or prosthetic wirsungoplasty).

The problem to be solved when performing open stenting of the pancreatic duct is to restore the drainage function of the pancreatic ductal system by creating an artificial passage in the parenchyma of the pancreatic head, connecting the lumen of the main pancreatic duct with the lumen of the duodenum, and the stent installed in the duct and artificial course ensures the drainage function .

The invention consists in the following. An upper mid laparotomy and a thorough revision of the organs of the hepatopancreatobiliary zone are performed. After the elimination of the rough periprocess and assessment of the condition of the surrounding organs, the duodenum is mobilized according to Kocher and the gastrointestinal ligament is mobilized. The front surface of the pancreas is exposed. If the expanded main pancreatic duct (GLP) is well palpated, then immediately or after preliminary puncture, a longitudinal pancreatotomy is performed in the body area with autopsy of the GLP. Sometimes palpation to detect GLP is difficult, especially in the presence of an infiltrative process. In this case, an intraoperative ultrasound is necessary. Under the control of ultrasound, a puncture of the duct is performed, the success of which is indicated by the receipt of light pancreatic juice, and then pancreatotomy is performed. Next, instrumental examination of the duct in the distal and proximal direction is performed. Its patency, the presence of stones and strictures along it are determined. The next step is a duodenotomy in the area of the lateral wall of the middle third of the descending part of the duodenum opposite the large duodenal papilla with a length of about 15-20 mm. The index or middle finger of the surgeon's left hand is inserted into the lumen and abuts against the area of the medial wall adjacent to the head of the gland. Then, with the right hand of the surgeon, a bougie with a removable head and a plastic tube previously put on it is inserted through the pancreatotomy hole. The bougie advances in the proximal direction to the site of obliteration of the duct. The extent of the obliteration zone, in which an artificial passage in the gland parenchyma is to be created, is estimated. In an obtuse way, under the control of the surgeon's hands, an artificial course is made in the pancreas head and the bougie is made into the lumen of the duodenum through its medial wall closely adjacent to the pancreatic head. This is the most crucial moment of the operation. It is necessary to spend time in order to correctly calculate the force and choose the right direction, since the artificial course must strictly pass through the adjoining area. With the left hand, the surgeon exercises control and prevents the “bougie’s head” from falling into the area outside the adjoining zone, since the effort to create an artificial course can be very significant. The removable bougie head having a thread is removed. The tip of the conductor tube protruding into the lumen of the duodenum is held by the hand of the surgeon. Bougie is removed. A stent is inserted through the conductor tube. The conductor tube is removed. The stent is installed throughout the GLP so that the stent tip protrudes about 10 mm long into the lumen of the duodenum with a lateral opening and a lateral retainer deflected to the side, preventing the stent from migrating into the gland. The pancreatotomy opening is sutured with a continuous return suture.

The normal functioning of the stent is determined by the expiration of drops of clear pancreatic juice from it with a slight compression of the gland.

The duodenotomy opening is sutured in the usual manner. The operation ends with drainage of the small omentum bag and suturing of the “window” in the gastrocolic ligament.

The technical result that is achieved by the implementation of the claimed method is to restore the drainage function of the pancreatic ductal system by creating an artificial passage in the parenchyma of the pancreatic head connecting the lumen of the main pancreatic duct with the lumen of the duodenum, and the stent installed in the duct and artificial course ensures the drainage function preferably made of a material that allows the stent to function effectively for pouring time (year or more).

Signs that allow you to recognize the claimed method of surgical intervention in accordance with the criteria of "novelty" and "inventive step" are the following:

- A new type of draining pancreatic surgery has been developed;

- restoration of the drainage function of the pancreatic duct system occurs by creating an artificial passage in the parenchyma of the pancreatic head connecting the lumen of the main pancreatic duct with the lumen of the duodenum;

- maintaining the drainage function is provided by the stent installed in the duct and artificial course;

- A technology has been developed to create an artificial stroke to the pancreatic head and to install a pancreatic stent.

Using the proposed method for surgical treatment of patients with chronic and acute pancreatitis complicated by pancreatic hypertension, it is possible to achieve the following results:

- reliably relieve pain;

- reduce the number of postoperative complications;

- restore the flow of pancreatic juice into the lumen of the duodenum;

- to exclude the progression of exo- and endocrine pancreatic insufficiency associated with a decrease in the volume of the functioning parenchyma in the resection of surgical intervention;

- stop acute, continuously recurring pancreatitis associated with pancreatic hypertension, resistant to conservative therapy, in which this method is non-alternative;

- improve the quality of life of patients.

The operations carried out in accordance with the method described above confirmed its effectiveness in restoring the drainage function of the pancreatic ductal system using plastic and nitinol stents.

Initially, when implementing the method, pancreatic stents manufactured in Ireland by SOOC were used, with a diameter of 7 to 10 FR with a length of 8-11 cm. However, when examining the stents removed after 10-12 months, it became clear that their clearance, as well as all the lateral openings, were completely clogged. The plastic of which the stent is made blackens, loses elasticity and becomes brittle. Apparently, the functioning of the lumen is possible only the first few months after surgery. Subsequently, the stent serves as a framework supporting the functioning of the canal, and pancreatic juice seeps through the prosthetic space.

Then, the claimed method was carried out using nitinol pancreatic stents with a polyurethane coating. A self-expanding stent with a diameter of 4 mm and a length of 28 mm was to support the patency of the artificial course created in the head. In total, 4 such stents were installed, 3 of them during surgery and 1 stent was installed endoscopically during the planned replacement of the SOOK stent. The postoperative period in all patients proceeded smoothly. On the 10th day after the operation, the patients were discharged. A follow-up examination after 2 months revealed the disappearance of pain and weight gain. 5 months after surgery, the patient is 30 years old; intense pain in the upper abdomen and hectic temperature appeared. With duodenoscopy, a stent is visible, the lumen of which is completely obturated with a yellowish mass, pancreatic juice does not enter the duodenum. A self-expanding nitinol stent, tightly pressed against the walls of the artificial passage and the Wirsung duct in the pancreatic head, leaves no room for paraprothetic drainage and completely blocks the lumen when the stent is obstructed, which occurs 5 months after its installation.

It should also be noted the following. Known stents are suitable for use in the implementation of the claimed method and confirm its effectiveness in achieving the above results. However, it is desirable to improve them, aimed at their longer functioning and stronger retention inside the gland, which counteracts migration.

A solution that meets these requirements was found when using a thermoplastic block copolymer - polyether blockamide for stents.

As it turned out, the surface of these stents during their stay in the body is able to inhibit the blockage of internal gaps. At the same time, the complex of physicomechanical, physicochemical and biomedical characteristics of stents is maintained at the level of products made from known polyurethanes, and even surpass them. The use of a stent from the specified material allowed to increase the period of its operation up to a year or more.

Examples of the method including the use of a stent made of polyester blockamide are given below.

Example 1. Patient S., 33 years old, was in the emergency surgery department from 08/04/2010 to 08/18/2010. Clinical diagnosis. Primary: Chronic inductive pancreatitis, a constantly recurring pain form. Complications: Pancreatic hypertension. Exocrine pancreatic insufficiency. Exhaustion.

He was admitted with complaints of pain in the upper abdomen after each meal, nausea, weight loss. From the anamnesis. In 2007, he was treated conservatively for acute destructive pancreatitis. Subsequently, during 2007, he was hospitalized three times with exacerbation of pancreatitis. During 2008-2009 He was hospitalized 8 times in the department of gastroenterology, he underwent endoscopic papillosphincterotomy (EPST), after which he noted a short-term improvement. Any meal causes pain. The main food is oatmeal on the water. He often used octreotide treatment for pain relief. With a height of 174 cm, it weighs 46 kg. Body mass index 15.2. Does not work due to illness. When ultrasound from 08/09/2011: the pancreas is reduced in size, without clear contours, the parenchyma is heterogeneous, increased echogenicity. Wirsung duct expanded to 8 mm in the body and tail, signs of sclerosis of the pancreas. 08/09/2011, open stenting of the pancreatic duct was performed. During surgery: the pancreas is sharply reduced in size, fibro-changed, the parenchyma is thinned, the pattern is not traced. The head is dense, bumpy. The main pancreatic duct is sharply expanded in the body and tail, fluctuates. The transverse size of the body and tail is 10-12 mm with a duct width of 8 mm. Pronounced cicatricial peripancreatitis, posterior perigastritis and periduodenitis. Pancreatotomy with a section of 17 mm, opened GLP. Pancreatic juice was poured out. A bougie with an olive diameter of 3 mm does not pass into the duodenum, encountering an obstacle at a distance of 10 mm from its medial wall. Duodenotomy of the lateral wall of the duodenum in the middle third of the descending part. The bougie was forced through the parenchyma of the gland and the medial wall of the duodenum into its lumen. Through the created artificial passage along the conductor, a SOOC 7 Fr stent of 11 cm length was installed. Pancreatotomy and duodenotomy openings are sutured. The abdominal cavity is drained. The postoperative period was uneventful. Primary healing. Discharged on the 9th day after the operation. When viewed after 6 months. There is no pain. He eats, in his words, everything. Weight is 58 kg. He gained 12 kg in weight. At control ultrasound: Virsungov duct is not expanded, in the lumen - a stent. Endoscopic stent replacement was performed 1 year after surgery. Subsequently, replacements were carried out annually.

Example 2. Patient A., 63 years old, was hospitalized in the surgical department from 02/13/2014 to 04/02/2014. Clinical diagnosis: Acute pancreatitis. Complications: Sepsis. Enzymatic ascites-peritonitis. Bilateral hydrothorax. Pancreatogenic infiltrate. Pancreatic and biliary hypertension. Pancreatic calculosis. Cachexia. Anorexia.

He was admitted with complaints of weakness, pain in the epigastrium and hypochondria, heaviness in the abdomen and increase in its volume, decreased appetite, weight loss. Sick since December 2013. He was treated in the surgical department with a diagnosis of acute pancreatitis in the presence of chronic pancreatic hypertension. Pancreatogenic infiltrate, omentobursitis, retroperitoneal fluid accumulations. Conducted conservative therapy with a positive effect. The condition improved, the temperature returned to normal, retroperitoneal fluid accumulations regressed. Discharged in January 2014, the patient was scheduled to perform open stenting of the pancreatic duct 2-3 months after the acute inflammatory process subsided.

Re-hospitalized in February 2014 due to worsening condition. In case of emergency ultrasound: Acute pancreatitis with infiltrative changes in the parapancreatic tissue, the walls of the duodenum, bags of the small omentum, with fluid accumulation in the bag of the small omentum. Extension of the Wirsung duct. In all parts of the abdominal cavity, a large amount of free fluid. In the biochemical analysis of blood, a significant increase in blood amylase was reached to 1,500. Conservative therapy was carried out in the department (infusions, parenteral nutrition, antibiotics, octreotide, gordox, etc.). Ascitic fluid in a volume of 4 l was removed during laparocentesis, the apparatus does not determine the amylase content in ascitic fluid, because it is prohibitively high.

Despite the ongoing intensive care, the condition progressively worsened. The pain syndrome persisted, exhaustion increased, and hyperthermia appeared. The amylase content in the blood increased to 2330. The patient's appetite completely disappeared, and his mental status changed. There were signs of twilight consciousness, apathy. Weight 49 kg, height 170 cm. Given the presence of ascites and hydrothorax, its true weight was not more than 44-45 kg. A body mass index of 15.2 corresponded to extreme exhaustion. Under the control ultrasound of February 25, 2014: the pancreas is 33 × 17 × 23 (the tail is not visible in full), the contours of the head are blurry, fuzzy, the infiltrate consisting of the head of the pancreas, the walls of the duodenum and the area of low echogenicity is also determined there 27 × 17 × 16 mm. Wirsung duct expanded to 8 mm. In all parts of the abdominal cavity free fluid, approximately 3 liters. Under the control ultrasound from 02.28.2014: the Virsung duct expanded to 9.5 mm, the infiltrate is maintained in its previous form. Free fluid in all parts of the abdominal cavity with a volume of approximately 5-6 liters. X-ray of the stomach from 02/27/2014: The act of swallowing is not broken, we pass the esophagus, it is somewhat enlarged, a sliding hernia of the esophageal opening of the diaphragm. The stomach is of the usual form, there is a narrowing of the output section and in the area of the duodenal bulb, the duodenum with thickened folds, the passage from the stomach and duodenum is slowed down. When CT scan dated 03/05/2014: CT scan of chronic pancreatitis in the acute phase, with the presence of pseudocysts. Severe biliary and pancreatic hypertension. Ascites with a volume of at least 4 liters.

The presence of pancreatic hypertension did not allow the patient to be taken out of the acute process, and the metabolic decay processes reached an almost irreversible level. It was decided to perform open stenting of the pancreatic duct almost as a despair operation.

Operated on 07.03.2014. During the operation: About 4 L of a clear yellowish liquid was evacuated from the abdominal cavity. In the pelvic cavity, the fluid was cloudy, there were overlays of fibrin. Liver of normal size, cherry color, normal pattern, the edge is pointed. The stomach is slightly enlarged, its wall is infiltrated and hyperemic. Severe infiltrative duodenitis. Behind the stomach, infiltrate is palpated, extending down to the mesokolon and the root of the mesentery of the small intestine and up to the hepatoduodenal ligament. Omentums and mesentery with few plaques of steatonecrosis. Pronounced periduodenitis and peripancreatitis. Back perigastritis. The gall bladder is not tense.

Mobilization of the gastrointestinal ligament. Isolated from the accretions in the organization stage, the anterior surface of the pancreas. Tissues are infiltrated, inflamed, bleed easily. Due to pronounced infiltrative changes, it is impossible to visually and palpate differentiate the lower and upper edge of the gland in the region of the head and body.

An intraoperative ultrasound scan was performed, with the help of which the Virsung duct was punctured. Performed pancreatotomy, Wirsung duct opened. Pancreatic juice is freely poured. The bougie passes freely in the distal direction. When bouginating in the central direction, an obstruction occurs 3 mm from the wall of the duodenum. With a little effort, the bougie was drawn into the lumen of the duodenum through its medial wall in the lower third of the descending section. Duodenotomy performed. In the main pancreatic duct, a polyetherblockamide stent with a diameter of 9 FR and a length of 9 cm is installed. Duodenotomy and pancreatotomy openings are sutured. The abdominal cavity is washed, drained and drained. The surgical incision is sutured.

In the postoperative period continued parenteral nutrition, infusion, antibacterial therapy. No complications were noted. The amylase level on the 5th day after the operation dropped to normal numbers, and body temperature returned to normal. The outflow of ascitic fluid along the drainage from the abdominal cavity was noted. Evasion of pancreatic juice is not marked. Sutures were removed on the 14th day. Primary healing. The general condition gradually improved, appetite appeared, became active, mood improved. Discharged.

Control examination 2 months after surgery. There is no pain. It eats normally. Weight 63 kg. He gained 14 kg in weight. Analyzes are within normal limits. Ultrasound: chronic calculous pancreatitis, pancreas 32 × 15 × 17 mm, infiltrative changes completely regressed. Wirsung duct is not expanded. There are residual ascites, the total volume of free fluid in the abdominal cavity is about 320 ml. There is no fluid in the pleural cavities. With duodenoscopy, a functioning pancreatic stent is visible, its walls are clean, without sticking, the lumen is free. 10 months later after the operation, she feels well, no pain, weight gain - 20 kg. An endoscopic stent replacement was performed. When examining the extracted stent, it turned out that it has small adhesions on the walls, its lumen is passable.

Example 3. A patient, 64 years old, 09/22/2014, operated on for chronic inductive calculous pancreatitis, complicated by pancreatic and biliary hypertension. An open stenting of the pancreatic duct was performed; a stent was made of polyester blockamide with a diameter of 9 Fr and a length of 100 mm. At the control examination after a year, the patient assessed his condition as good. There are no pains, there is no shortage of body weight. 09/10/2015, a planned replacement of the pancreatic stent was performed. With pancreatography, the pancreatic duct is not dilated. We pass the extracted stent, its holes are clean.

As follows from the above examples, open stenting of the pancreatic duct, performed by open surgery, significantly expands the possibilities of applying the method.

Claims (2)

1. The method of surgical treatment of chronic pancreatitis complicated by pancreatic hypertension, which consists in performing longitudinal pancreatotomy in the body area with opening the main pancreatic duct, performing duodenotomy in the lateral wall of the middle third of the descending part of the duodenum opposite the large duodenal papillum glands in the obliteration zone of the ductal system through the pancreatotomy opening enter the bougie with a removable head and a plastic tube with a conductor-guide and push it in the proximal direction to the site of duct obliteration, then an artificial passage is created in the head of the pancreas, for which the bougie is drawn into the lumen of the duodenum through its medial wall closely adjacent to the head of the pancreas, the removable head is removed and the bougie is removed , a stent is inserted through the conductor tube, the conductor tube is removed, after which the pancreatotomy opening is sutured. 2. The method according to p. 1, characterized in that the stent is replaced by endoscopic manipulation once a year.