RU2698873C1 - Method of forming hepaticojejunostomy with high bile duct injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used to form hepaticojejunostomy with high bile duct injury. Drainage chlorovinyl tube with diameter of 5 mm is inserted through a free end of the stump of the mobilized intestine and fixed first with a catgut suture, and then with continuous two semi-cartridges. Then, 5–6 cm from the plugged end of the intestine is made, a wall of a mobilized intestine is cut 4 cm long to a submucosal layer. Thereafter, the vessels in the submucosal layer are sutured with the catgut on one and the other side. Intestinal lumen is opened between the rows of applied sutures. Medial angle of the opened lumen of the intestine is then anchored to the round ligament of the liver with long-term absorbable sutures. Further, with a continuous blanket suture, the posterior lip of the intestine behind the hepatic ducts is anchored to the connective tissue structures of the hepatic ligament, the lateral angle of the opened lumen of the jejunum is anchored to the gall bladder bed at the junction of the sagittal sulcus with the lateral ligament. Then anterior lip of jejunum is hemmed in front of hepatic ducts by sutured suture to edge of transverse furrow and tightened suture on round ligament of liver. In the end seromuscular sutures are laid between a Y-shaped loop in the liver gates and separate cicatrical structures.

EFFECT: method enables avoiding the complications associated with injuries of the biliary duct system.

1 cl, 4 dwg

Description

The invention relates to medicine, in particular to human abdominal surgery, and can be used in clinics of various levels of equipment, starting from the surgical departments of multidisciplinary hospitals, ending with specialized centers of abdominal surgery.

P. et al. Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis. World J Gastroenterol. 2013 Nov 28; 19(44):8047-55; Severini A., Cozzi G., Salvetti M., Mazzaferro V., Doci R. Management of complications from hepatobiliary surgery using the percutaneous transjejunal approach. Tumori 1997 Nov-Dec: 83(6): 912-917). Дилатация структур, экстракция конкрементов, стентирование, биопсии являются традиционными вмешательствами у больных с наложенным гепатикоеюноанастомозом в отдаленном периоде после операции (Castaing D., Azoulay D., Bismuth H. Percutaneous catheterization of the intestinal loop of hepatico-jejunostomy: a new possibility in the treatment of complex biliary diseases. Gastroenterol Clin Biol, 1999 Aug-Sep; 23(8-9):882-6).Currently, in the surgical treatment of bile duct lesions, the priority is the application of hepaticoyunoanastomosis on a loop disconnected along the Ru, since this method eliminates the reflux of intestinal contents into the biliary tree, and also reduces the risk of anastomotic insolvency. Most domestic and foreign authors prefer the formation of hepaticoyunoanastomosis, during which a clear comparison of the mucosa of the biliary tract and the mucosa of the small intestine is carried out. Based on the generalized experience of 160 reconstructive operations, Tishchenko AM et al. (Tishchenko AM, Boyko V.V., Smachilo PM, Skory DI. Treatment of postoperative stricture of the bile ducts: 15 years of experience and observations from practice. Clinical surgery. 2015; ( 9): 12-5) consider the primary formation of hepaticoyunoanastomosis on the Ru loop to be appropriate according to the above methodology, which provides the precise formation of an anastomosis with a clear comparison of the mucous membranes, which can significantly reduce the incidence of early and late specific complications. Frequency of biliary complications (insolvency was noted in 15.21%, anastomotic stenosis in 4.34% of cases). It was found that a type and technique of biliary reconstruction had a statistically significant effect on the frequency of biliary complications. The authors also point out the need for adaptation of the elements of the biliary tree and the anastomosed small bowel cult (Brasoveanu V., Anghel C., Bacalbasa N. et al. Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors. Chirurgia (Bucur). 2014 Jan-Feb; 109 (1): 15-9). Moreover, the percentage of patients with postoperative biliary tree strictures is quite high, which many authors decide to use percutaneous methods of drainage of the ducts of the liver with subsequent balloon dilatation (Kianicka B., Lata J., Novotny I,

P. et al. Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis. World J Gastroenterol. 2013 Nov 28; 19 (44): 8047-55; Severini A., Cozzi G., Salvetti M., Mazzaferro V., Doci R. Management of complications from hepatobiliary surgery using the percutaneous transjejunal approach. Tumori 1997 Nov-Dec: 83 (6): 912-917). Structural dilatation, calculus extraction, stenting, and biopsies are traditional interventions in patients with superimposed hepatikojunoanastomosis in the long term after surgery (Castaing D., Azoulay D., Bismuth H. Percutaneous catheterization of the intestinal loop of hepatico-jejunostomy: a new possibility in the treatment of complex biliary diseases. Gastroenterol Clin Biol, 1999 Aug-Sep; 23 (8-9): 882-6).

In this regard, it can be stated that the formation of biliodigestive anastomoses is associated with a number of early and late complications, requiring both minimally invasive and traditional surgical interventions, which undoubtedly increase the risk of an adverse outcome from treatment.

For the prototype, we chose a method for the formation of choledochojejunoanastomosis, which was carried out as follows: after isolation and opening of the stump of the common hepatic duct, scar tissue was excised proximal to the stricture, then the anastomosis posterior and anterior lips were formed with the ends of the threads fixed at the edges of the anastomosis and left free, which reduced the likelihood of not reaching or pulling the threads and ensured a uniform density of matching fabrics, then the free ends of the threads were tied together (Prudkov M.I., Titov K. ., Shushan AP Surgical treatment of cicatricial strictures of the common hepatic duct surgery Annals of Hepatology 2007 (12/2):.. 69-74).

The disadvantages of this method are the difficulties in the formation of the posterior and anterior lips of the anastomosis, the need for excision of scar tissue, which prevent bile leakage into the free abdominal cavity and prevent the dislocation of the Ru-loop in the postoperative period, as well as the possibility of a long period of stricture development in the anastomosis zone, as well as hepaticolithiasis .

Technical result: to form such a method of treating high damage to the bile ducts, in which the application of hepaticoyunoanastomosis will occur without serious complications associated with trauma to the biliary duct system.

The technical result is achieved by the fact that in the formation of hepaticojejunostomy on the Ru loop with the fixation of the disconnected loop to the scar tissue and connective tissue structures of the liver gates, the formation of a reservoir in which the stump of hepaticoholedocho is located freely, without additional fixation and matching of the mucous bile ducts and jejunum, and decompression the area of the anastomosis is achieved by drainage through the stump and the removal of vinyl chloride drainage to the median wound.

The invention is illustrated by the figures:

- in FIG. Figure 1 shows the formation of a U-shaped loop with the staging of the mobilized stump of the decompression vinyl chloride drainage into its free end.

- in FIG. 2 shows the formation of the posterior lip of hepaticoyunoanastomosis.

- in FIG. 3 shows the formation of the anterior lip of hepaticoyunoanastomosis.

- in FIG. 4 shows a formed reservoir into which the right and left hepatic ducts open.

The method is as follows.

Retreating from the Treitz ligament of 15-20 cm, the U-shaped loop of the jejunum 40-45 cm long is mobilized (Fig. 1. 3), its end is sutured with a continuous catgut suture and peritonized with two half-sets, the intestinal tube is restored by applying the inter-intestinal anastomosis side to side (Fig. 1. 1), a mobilized U-shaped loop is carried out behind the colon to the gate of the liver (Fig. 1. 2).

Through its free end, a drainage tube (Fig. 1. 4) with a diameter of 5 mm is inserted into the lumen of the mobilized stump with the purpose of decompression, followed by fixation of the tube with a catgut suture and then continuous two half-sets.

Retreating 5-6 cm from the muffled end of the intestine, a section of its wall 4 cm long is made (Fig. 2. 3) to the submucosal layer, with thin catgut on one side and the other side, the vessels in the submucosal layer are stitched and, thus, we achieve reliable hemostasis, between the rows of the sutures, the intestinal lumen is opened (Fig. 2. 3), with long absorbable threads, the medial angle of the opened intestinal lumen is sutured to the round ligament of the liver (Fig. 2. 4), then, the posterior intestinal lip behind the hepatic ducts is continuously twisted up and down (Fig. 2. 2) hemmed to the connective tissue m structures of the round ligament of the liver surrounding its own hepatic artery, portal vein; the lateral angle of the open lumen of the jejunum is sutured to the bed of the gallbladder (Fig. 2. 1, Fig. 3. 1), approximately at the junction of the sagittal groove with the transverse, then the front lip (Fig. 3 2) of the jejunum (Fig. 3. 3) is sutured in front of the hepatic ducts with a curved suture to the edge of the transverse groove and the suture is tightened on the round ligament of the liver (Fig. 3.4), thereby forming a reservoir from the jejunum in the liver gate, into which the hepatic ducts open (Fig. 4), an additional fixation of the U-shaped loop in the gate of the liver is reached aniem U-loop individual sero-muscular sutures scar formation to the gate of the liver and to the edge of the slit venochnoy ligament.

In order to decompress the mobilized loop of the small intestine, a vinyl chloride tube with a diameter of 5 mm is produced through its stump, which is displayed on the skin through a separate puncture. Drainage is removed 12-14 days after surgery.

An example of a specific application.

Extract from the medical history.

Patient K.

Date of receipt: 10/26/2017. Date of discharge: 11/20/2017.

Clinical diagnosis:

Primary: gallstone disease.

Complication of the main: a secondary wrinkled gall bladder, cholecysto-choledochial fistula (Mirrisi syndrome type IV), choledocholithiasis, chronic cholangitis.

Concomitant diagnosis: chronic gastroduodenitis; arterial hypertension of the II degree, II stage, risk 3; left ventricular myocardial hypertrophy.

Patient K. was admitted to the surgical department of the OBUZ Kursk City Clinical Hospital No. 4 in a planned manner with complaints of pain in the right hypochondrium and bitterness in the mouth arising from a violation of the diet. After preoperative preparation and further examination, the patient was diagnosed with gallstone disease, a secondary wrinkled gall bladder, chronic cholangitis.

The results of laboratory and instrumental studies.

General blood test at admission: erythrocytes 3.6 × 10 ¹² / l, hemoglobin 107 g / l, color index 0.9, white blood cells 5.8 × 10 ⁹ / l: stab-core - 2%, segmented - 71%, eosinophils - 1%, lymphocytes - 22%, monocytes - 4%, erythrocyte sedimentation rate of 7 mm / h.

General analysis of urine at admission: color - straw yellow, partial transparency, density 1014, reaction - acidic, protein - no, flat epithelium 4-8 in the field of view, white blood cells 4-6 in the field of view.

Biochemical analysis of blood at admission: total protein - 64.0 g / l, bilirubin - 12.0 μmol / l, direct - 6.0 μmol / l, indirect - 6.0 μmol / l, creatinine - 67.0 μmol / l, glucose - 5.6 mmol / l. APTTV - 24 sec.

Ultrasound examination of the abdominal organs upon admission. The liver is not enlarged, increased echogenicity, homogeneous, vascular pattern is depleted, intrahepatic bile ducts are not enlarged, choledoch 12 mm, its wall thickened to 3 mm, signs of chronic cholangitis. The gall bladder is wrinkled a second time, the lumen is completely filled with calculi. The pancreas is not enlarged, increased echogenicity, head 24 mm, body 16 mm, tail 22 mm. Pancreatic duct is not expanded - 2 mm. The kidneys are usually located without signs of urostasis. The spleen is not enlarged, homogeneous. Loops of the intestine are not expanded, peristaltic. There is no free fluid in the abdominal cavity.

It was decided to perform video laparoscopic cholecystectomy with a possible transition to laparotomy. During video-laparoscopic cholecystectomy, mobilization of the gallbladder, it was found that the patient has type IV Mirrisi syndrome (the presence of the cystic-choledochal fistula, which occupies the entire circumference of the liver duct, with the duct wall completely destroyed). It should be noted that in this case, when mobilizing the gallbladder, the common hepatic duct opened at a distance of 1 cm from the confluence of the right and left hepatic ducts. Considering the presence of a defect in the total hepatic flow at such a high level, it was decided to perform laparotomy and to apply hepaticoyunoanastomosis according to the proposed method.

The operation was performed: laparotomy, mobilization of the loop of the small intestine according to Ru, the formation of hepaticoyunoanastomosis, external drainage of the U-shaped loop, drainage of the abdominal cavity.

The postoperative period was uneventful. In the postoperative period she received complex conservative therapy: broad-spectrum antibiotics, infusion therapy with antispasmodics, analgesics, and local treatment.

In the postoperative period of bile leakage, there was no positive dynamics: pain was stopped, dyspeptic symptoms were not observed. Feeding the patient started from 5 days of the postoperative period. The postoperative wound healed by first intention, the sutures were removed.

The results of laboratory and instrumental studies.

General blood test at discharge: erythrocytes 3.4 × 10 ¹² / l, hemoglobin - 101 g / l, color index - 0.84, white blood cells 7.3 × 10 ⁹ / l: stab count - 3%, segmented - 61%, eosinophils - 2%, lymphocytes - 31%, monocytes - 3%, erythrocyte sedimentation rate - 10 mm / h.

General analysis of urine at discharge: straw color, partial transparency, density 1017, reaction acidic, protein 0 g / l, flat epithelium 5-6 in the field of view, white blood cells 4-8 in the field of view.

Biochemical analysis of blood at discharge: total protein - 53.3 g / l, bilirubin - 11.7 μmol / l, creatinine - 60.0 μmol / l, glucose - 5.0 mmol / l. APTTV - 30 sec.

Ultrasound on discharge. The liver is not enlarged, increased echogenicity, homogeneous, vascular pattern is depleted. Intrahepatic passages are not dilated, the right and left hepatic ducts are up to 8 mm, the common bile duct is up to 8 mm, is not located throughout. In the gallbladder bed, a fixed loop of the small intestine is determined. The pancreas is not enlarged: head - 26 mm, body - 18 mm, tail - 22 mm; increased echogenicity due to fibrosis. Pancreatic duct is not expanded. Kidneys - without signs of urostasis The spleen is not enlarged, homogeneous. Loops of the intestine are not expanded, peristaltic. There is no free fluid in the abdominal cavity.

The patient was discharged in satisfactory condition under the supervision of a gastroenterologist and the surgeon of the clinic at the place of residence.

Thus, when using this method of the formation of hepaticoyunoanastomosis on a U-shaped loop, it is noted:

1) Preventing the occurrence of specific complications in the form of leakage of bile from the suture line of hepaticoyunoanastomosis due to the discharge drainage system.

2) Prevention of arrosive bleeding in the zone of formation of the reservoir by providing reliable hemostasis, achieved by flashing the vessels in the submucosal layer with a thin catgut on one or the other side.

3) Ensuring the free discharge of bile into the intestine with a minimal risk of developing insolvency or stricture of hepaticoyunoanastomosis; fast, relatively prototype method, restoration of the functions of the gastrointestinal tract and metabolic processes.

4) Due to the additional fixation of the U-shaped loop in the gates of the liver by individual sero-muscular sutures to the cicatricial formations of the gates of the liver and to the edge of the crevice of the coronary ligament, a reduction in the tension of the threads in the area of hepaticojejunanastomosis is ensured, which prevents the eruption of tissues, thereby ensuring the tightness of the anastomosis.

Claims (1)

A method for the formation of hepaticoyunoanastomosis with high damage to the bile ducts, including turning off the jejunum segment according to Ru, characterized in that a 5 mm diameter PVC drainage tube is inserted through the free end of the mobilized intestine stump and it is fixed first with a catgut suture and then with continuous two half-bunches, then retreating 5 -6 cm from the muffled end of the intestine, make a section of the wall of the mobilized intestine 4 cm long to the submucosal layer, after which vessels are sutured into the submucosa with catgut on one side and the other that layer; between the rows of sutures, the intestinal lumen is opened, then the medial angle of the opened intestinal lumen is sutured to the round ligament of the liver with long absorbable sutures and then the posterior intestinal lip behind the hepatic ducts is sutured to the connective tissue structures of the round ligament of the liver with a continuous upholstered suture, the lateral angle of the opened lumen of the jejunum the gallbladder at the junction of the sagittal groove with the transverse, then the anterior lip of the jejunum is sutured in front of the hepatic ducts with an upholstered suture to edge of the transverse groove and tighten the suture on the round ligament of the liver; at the end, sero-muscular sutures are placed between the U-shaped loop in the gate of the liver and its individual scar formations.

Images