RU2716342C9 - Method of surgical treatment of patients with tumor involvement of duodenum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to oncology and abdominal surgery and can be used for surgical treatment of patients with tumor duodenal involvement. Duodenum is mobilized from pancreatic tissue with separate dressing of front and posterior short duodenal vessels and preservation of anterior and posterior pancreaticoduodenal vascular arches. A circular resection of not only a lower-horizontal, but a distal portion of the descending duodenum is carried out at least 3 cm from the bile papilla with formation of iso- or anti-peristaltic duodenojejunal anastomosis as "side-to-side".

EFFECT: method provides high reliability and functionality of the anastomosis ensured by anatomically justified mobilization of duodenum from pancreatic tissue.

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Description

The invention relates to medicine, namely to oncology, abdominal surgery and for the surgical treatment of patients with tumor lesions (primary tumors or secondary tumor invasion from the outside) of the duodenum (duodenum).

Gastropancreatoduodenal resection (DHD) is the standard volume of surgery for tumors of the duodenum [Journal Annals of Surgery 2006; 244 (6): 931-939]. The method consists in the fact that at once, in a single block, the entire duodenum with the initial jejunum, the head of the pancreas, the exit section of the stomach with the adjacent small omentum and the right half of the omentum, gall bladder, common bile duct adjacent to the pancreatic head are removed , fascial-cellular cases of the common and own hepatic arteries, trunks of the superior mesenteric vessels and portal vein.

The operation is performed from the median laparotomic access. After dissection of the gastrocolic ligament, KDP is mobilized according to Kocher with the allocation of the superior mesenteric and portal veins. Next, mobilization of the gallbladder with lymphatic dissection along the hepatoduodenal ligament and the intersection of the common bile duct above the confluence with the cystic duct is performed. The stomach is mobilized along both curvatures with ligation of the right gastric and gastrointestinal vessels. The gastroduodenal artery is separately isolated and bandaged. A tunnel forms between the isthmus of the pancreas and the portal vein. The pancreas intersects at this level. The next step is the linear stapler apparatus is the intersection of the stomach and jejunum. In the proximal direction, the mesentery of the resected jejunum intersects. Further, the entire complex is mobilized from the superior mesenteric vessels and removed. In the process of mobilization, the lymph nodes of the following regional groups are removed: supra- and infra-pyloric (No. 4 and 5), hepatoduodenal ligaments (No. 12 a, b, c, p and h), along the upper and lower edges of the pancreatic head (No. 11 and 18) , anterior and posterior pancreatoduodenal (No. 13) and proximal mesenteric (No. 14). There are various variations of the reconstructive stage, which consists in restoring the gastrointestinal tract with the obligatory inclusion of the pancreas and the common hepatic duct.

The disadvantages of DAD are: high postoperative morbidity (postoperative complications develop in 30-70% of patients), high postoperative mortality (up to 5% in specialized clinics and up to 7-12% in non-core clinics), as well as a high level of functional disorders in the long-term postoperative period. The main problem of the operation is the failure of pancreaticoeunoanastomosis, the frequency of which reaches 30% and pancreatic necrosis of the pancreatic stump, which occurs in 0.5-9% of cases. Insolvency of a biliodigestive anastomosis develops in 9% of patients. More than 2/3 of patients develop exocrine and endocrine pancreatic insufficiency, which are manifested by malabsorption syndrome and insulin-dependent diabetes mellitus, which complicates the rehabilitation of patients, and in most cases lead to their disability.

According to the literature, with non-epithelial tumors (with the exception of lymphomas), economical, organ-preserving operations are justified. As a result of performing economical resections, the immediate results and quality of life of patients are significantly improved. At the same time, indicators of overall survival do not differ from the results of extended surgical interventions. Obligatory requirements for surgical intervention are the negative edges of the resection and preservation of the integrity of the tumor capsule [Zhou B, Zhang M, Wu J. Pancreaticoduodenectomy versus local resection in the treatment of gastrointestinal stromal tumors of the duodenum. World Journal of Surgical Oncology. 2013; 11 (1): 196. https://doi.org/10.1186/1477-7819-11-196]. Similar data are described in patients with duodenal adenocarcinoma (ADPK). According to many authors who compared the results of surgical treatment of patients with ADPK, differences in the long-term results after economical resections and HDL were not found [Hu JX, Miao XY, Zhong DW, Dai WD, Liu W, Hu W. Surgical treatment of primary duodenal adenocarcinoma . Hepatogastroenterology. 2006; 53: 858-862].

Another way of surgical treatment of patients with non-epithelial tumors of the duodenum is to perform wedge-shaped resection of duodenum. The method consists in the fact that the tumor is excised within the healthy tissue of the intestinal wall. Technically, the vector of resection and subsequent flashing of the bowel wall defect should be performed in the transverse direction relative to the duodenum vector. The main criteria for the radical nature of the operation are the negative edges of the resection. Therefore, an urgent histological examination is performed intraoperatively, and in the presence of tumor cells along the resection line, it is necessary to expand the scope of surgical intervention. [Chung JC, Kim NS, Hur SM. Limited resections for duodenal gastrointestinal stromal tumors and their oncologic outcomes. Surg. Today. 2016; 46 (1): 110-116. https://doi.org/10.1007/s00595-015-1163-x].

The disadvantage of this method is the risk of developing stenosis of the lumen of the intestine with a large area of tumor damage. Wedge resection is permissible only for small tumors or in cases when the tumor comes from the intestinal wall on a "thin leg".

When a tumor is localized in the descending part of the duodenum, methods for pancreatic preservation duodenectomy (PSD) are described in the literature. There are two types of PSD: typical and papillopreserving PSD (Yusuke Nakayama, Masaru Konishi, Naoto Gotohda et al. Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy. Surgery Today June 2017, Volume 47, Issue 6, pp. 705 -711). The method consists in the complete mobilization and removal of duodenum, followed by the formation of an anastomosis between the loop of the jejunum and the ampulla of the choledocho-pancreatic duct of the type "end to side". In terms of postoperative morbidity and functional characteristics, only papillopreserving PSD has a significant advantage over pancreatoduodenal resection. Postoperative complications and functional impairments after typical PSD are approximately the same compared to PDD, even higher by some authors (Michael W. Müller, MDa, b, Rolf Dahmen, et al. Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis? The American Journal of Surgery. 2008, 195, 741-748).

Closest to the claimed is a method of performing distal segmental (limited) resection of the duodenum (Ankush Golhar, * Vivek Mangla, et al. Limited distal duodenal resection: Surgical approach and outcomes. A case series. Ann Med Surg (Lond). 2018 Jun; 30 : 36-41. Doi: 10.1016 / j.amsu.2018.04.005). This method is used to localize the tumor in the lower horizontal and vertical sections of the duodenum and consists in limited circular resection of the distal duodenum with the formation of duodenojejunostomy on the type of "end to end", "end to side" or "side to side".

The disadvantage of this method is the limitation of its use in the localization of the tumor in the descending part of the duodenum.

The objective of the invention is the creation of a new method of surgical treatment of patients with tumor lesion of the descending part of the duodenum, free from the disadvantages of the prototype.

The problem is solved by the fact that they perform mobilization and circular resection of the distal part of the descending section, the lower corner, the lower horizontal and vertical sections of the duodenum, followed by the movement of the initial section of the jejunum to the right of the superior mesenteric vessels and the formation of duodenojunoanastomosis according to the “side to side” type. The limiting criterion for performing this volume of surgical intervention is the distance from the macroscopic edge of the tumor to the Vater papilla. The minimum distance at which we were able to perform a radical distal resection of the duodenum (DR duodenum) in a patient with HIS was 3 cm. When the tumor infiltration is located along the outer contour of the duodenum, the intestine can cross in the oblique direction, thereby expanding the indications for distal resection KDP at a distance of less than 3 cm from Vater's nipple. To achieve optimal conditions (reduction and devitalization of the tumor) to perform DR DPK, it is necessary to expand the indications for neoadjuvant therapy.

The technical result of the proposed method is the possibility of its wider application, high reliability and functionality of the anastomosis.

The inventive method is illustrated by examples 1-2 and figures 1 (A-D) and 2 (A-D).

In FIG. 1 (A-D) presents a diagram of the technical implementation of the distal resection (DR) of the duodenum.

In FIG. 2 (A-D) presents intraoperative photographs of the individual stages of the execution of DR DPK.

The method is as follows.

To perform distal duodenal resection, a median laparotomic approach is used. Mobilization of the duodenum according to Kocher is performed using Cattel-Braash. A leaf of the peritoneum is dissected along the right lateral canal from the level of the hepatoduodenal ligament to the dome of the cecum. Further, the peritoneal incision is continued to the left and cranially to the level of the Treytz ligament with mobilization of the right half of the colon and the entire small intestine with the mesentery, which are displaced to the left and up. As a result of this maneuver, the duodenum is exposed throughout its entire length. Next, they mobilize the lower horizontal, vertical sections of the duodenum and duodenojejunal transition with the intersection of the mesentery with the supply vessels. The mobilized part of the jejunum is transferred (removed) to the right of the mesentery of the small intestine (Fig. 1B and 2A). The most difficult stage is the mobilization of the lower corner and the descending part of the duodenum. In the process of their mobilization, the anterior and posterior short duodenal vessels are separately ligated with the preservation of the corresponding pancreatoduodenal vascular arches. If necessary, retroperitoneal lymphadenectomy is performed. A duodenum and an initial jejunum cross section with a linear stapler stapler (Fig. 1B and 2B). A mechanical suture on a jejunum stump is immersed in a purse string suture. The suture on the cult of the descending part of the duodenum, taking into account the limited distance to the Vater's nipple, is covered with separate nodular serous-muscular sutures (Fig. 1C). From our point of view, and according to the literature, the most reliable way to restore continuity of the intestinal tract is to perform duodenojejunostomy on the type of "side-by-side" (Fig. 1C, D; 2C, D).

Technically, anastomoses can form both iso- and anti-peristaltic.

The distal part of the jejunum is best suited for the formation of anastomosis posteriorly (through a window in the mesentery of the transverse colon) and anterior to the superior mesenteric vessels (Fig. 1C and 2D). With technical difficulties, it is possible to conduct an anastomosed loop of the jejunum behind the superior mesenteric vessels (in the bed of the removed lower horizontal and vertical parts of the duodenum) (Fig. 1D).

The proposed method differs from the prototype in the ability to perform a more extensive resection of the duodenum, including the removal of not only the lower horizontal part, but also the descending part of the duodenum, as well as an anatomically sound method of mobilizing the duodenum from the tissue of the head of the pancreas, which reduces the likelihood of damage to the parenchyma of the pancreas pancreatogenic complications (pancreatitis, pancreatic necrosis of pancreatic fistula).

This method of resection of the duodenum differs from the known high reliability and functionality of the anastomosis and the possibility of its wider use.

Example No. 1

Patient B., 69 years old.

Diagnosis: GISO of the duodenum pT4N0M0, MI - high, IIIB art. Condition after neoadjuvant therapy with imatinib 400 mg per day in 2017-2018. Partial regression.

Histological diagnosis: stromal tumor of the duodenum, spindle cell type of structure, with a high mitotic index (15 mitoses in 50 PZ x 400).

A patient was administered neoadjuvant therapy with imatinib 400 mg per day from August 2017 to October 2018 with a positive effect in the form of a tumor reduction from 15.5 cm to 7.5 cm. In November 2018, the N. N.N. Oncology Research Center for Oncology. Blokhin "Ministry of Health of the Russian Federation, the operation was performed according to the claimed method. After surgery, adjuvant therapy was started according to accepted treatment standards for 3 years. Currently, the patient is alive with no signs of disease progression.

Example No. 2

Patient A., 60 years old.

Diagnosis: Cancer of the transverse colon pT4bN0M0 - IIC Art.

Histological diagnosis: transverse adenocarcinoma, sprouting all layers of the colon wall and growing into the descending part of the duodenum.

To a patient in July 2017 at the Federal State Budgetary Institution Scientific Research Center for Oncology named after N.N. Blokhin "Ministry of Health of the Russian Federation, the operation was performed according to the claimed method. After the operation, 6 courses of adjuvant PCT were performed according to the XELOX scheme. Currently, the patient is observed without signs of disease progression.

Surgical treatment according to the claimed method was carried out in 11 patients with tumor of the duodenum. The average age of patients was 56 years (from 28 to 74 years). In all 11 cases, R0 resection was performed (without elements of tumor growth along the line of resection of the duodenum). Of these, in 9 patients with DR, duodenal ulcer was performed for primary duodenal tumors: in the 1st case of duodenal leiomyosarcoma, in the remaining 8 cases of GISO duodenum. Of 8 patients with duodenal GIS, 4 patients received neoadjuvant therapy with imatinib at a dosage of 400 mg per day with partial tumor regression. In the remaining 2 cases, distal duodenal resection was performed for tumor invasion from the outside: in 1 case of transverse colon cancer and in the second case, retroperitoneal non-organ tumor.

In all cases, we formed side-to-side anastomoses between the anteroposterior wall of the remaining descending part of the duodenum and the initial jejunum. In 10 (90.9%) cases, we formed isoperistaltic anastomoses, in one (9.1%) case - antiperistaltic.

Postoperative morbidity was evaluated according to the Clavien Dindo classification. In the early postoperative period, complications of 1-2 degrees developed in 4 (36.4%) patients. Complications of degree 2 were observed in 2 patients, of which one (9.1%) had pancreatic fistula, which closed against the background of conservative treatment. One patient was diagnosed with polysegmental pneumonia. Insufficiency of the duodenal stump and duodenojejuno anastomosis were not observed in all cases. There were no fatal outcomes in the postoperative period either. In the long term, we did not observe functional disorders of the gastrointestinal tract. Local relapses for the entire observation period were also not detected. Postoperative hospital stay averaged 13 days (10 to 16 days).

Thus, the inventive method is associated with low postoperative morbidity, good functionality and quality of life of patients, as well as a smaller number of days in hospital compared to advanced operations. Given the absence of differences in long-term results, economical resection of the duodenum, in particular DR duodenum, is the method of choice in patients with non-epithelial (with the exception of lymphomas), neuroendocrine tumors and secondary tumor invasion of the duodenum from the outside.

Claims (1)

A method for the surgical treatment of patients with tumor damage to the duodenum, consisting in distal duodenal resection with the formation of duodenojejunostomy and characterized in that the duodenum is mobilized from pancreatic tissue with separate ligation of the anterior and posterior short anterior duodenal and duodenal duodena circular resection of not only the lower horizontal, but also the distal part of the descending part of the duodenum, departing at least 3 cm from the Vater papilla with the formation of iso- or anti-peristaltic duodenojejunoanastomosis according to the “side to side” type.

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