RU2726603C1 - Method for treating an external fistula of the proximal pancreas following a gastrectomy or stomach resection with bilroth-ii reconstruction under ultrasound control and fluoroscopy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to abdominal surgery. Under ultrasound control, an introducer sheath with a needle is inserted through the fistulous passage and a medial wall of the duodenal stump is pierced. Introducer sheath is removed; a contrast agent is introduced through the needle to control the ingress of the needle into the lumen of the duodenal stump. Thereafter, a guide is inserted through the needle into the duodenum lumen, along the lower horizontal branch of the intestine behind the Hebrew bunch. Needle is removed. Conjunctival canal and duodenum bougienage is performed along the guide to the size of the drain tube. Further, a drain tube with side openings is installed along the guide so that part of the holes is located in the fistulous duct, and a part in the lumen of the duodenum. Fistulography is performed to monitor the standing of the drain tube. Drainage tube is fixed to skin; after one day, it is covered and, not earlier than 14 days later, is removed.EFFECT: method is aimed at reducing the traumatism of the manipulation and reducing the length of hospitalization, forming a physiological version of the pancreatic juice, that provides the cure of the patients with external pancreatic fistulas, which are impossible, for various reasons, to perform endoscopic stenting of the Wirsung duct, it is impossible to form an anastomosis between fistula and stomach.1 cl, 5 dwg, 5 ex

Description

The technical field to which the invention relates

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of chronic pancreatitis complicated by an external pancreatic fistula from the proximal pancreas in patients with a disabled duodenum after gastrectomy or gastrectomy according to Billroth-II.

State of the art

Over the past decades, there has been an increase in the incidence of acute pancreatitis. The destructive nature of OP develops in 15-30% of patients (Zubarev P.N. Causes of deaths in acute destructive pancreatitis / P.P. Zubarev, I.D. Kosachev, S.V. Paskar // Vestnik St. Petersburg. Univ. - 2009. - Cep. ll, Issue 4. - P. 161-168; Skutova V.A., Danilov A.I., Feoktistova Zh.A. Bulletin of the Smolensk State Medical Academy 2016, T 15, No. 2, 78-84).

External pancreatic fistula (LPS) is one of the outcomes of acute pancreatitis (OP) and a complication of chronic pancreatitis (CP) or operations on the pancreas (RV). The incidence of LPS formation after suffering from OP is 30-55%. (Possibilities of treatment of external pancreatic fistula [Text] / DV Cherdantsev, OV Pervova, V.Yu.Dyatlov, D.Sh. Kurbanov // Surgery. Journal named after N.I. Pirogov. - 2014. - N 8. - S. 62-66; Spanier B. W., Dijkgraaf M. G., Bruno M. J. Epidemiology, aetiology and outcome of acute and chronic pancreatitis: An update // Best Pract Res Clin Gastroenterol. - 2008 . - vol. 22, # 1. - p. 45-63).

For the treatment of fistulas, various options for operations are known from the prior art, including resection of the pancreas carrying the fistula, or the formation of various pancreatogastric and pancreato-intestinal anastomoses. Currently, new medical technologies are actively developing and minimally invasive techniques are being introduced, including percutaneous and endoscopic manipulations for the treatment of LPS (External and internal fistulas in a surgical clinic / Ed. By E.N. Vantsyan. - M .: Medicine, 1990. - 224 with: ill .; Ivshin, V.G. Method for the treatment of external pancreatic fistulas / V.G. Ivshin // Annals of surgical hepatology. - 2005.- Volume 10, No. 3. - P. 101-107; Grishin, I.N. Cysts, fistulas of the pancreas and their complications / IN Grishin, VN Grits, SN Lagodich. - Minsk: Higher school, 2009. - 272 p.). However, the methods for returning pancreatic juice known from these sources of information are not functional, close to the naturally physiological pathway. In addition, the known methods using open surgical access are characterized by high trauma, scarring of the anastomoses. The methods are characterized by the risk of developing diabetes mellitus, the risk of developing pancreatic necrosis.

Closest to the claimed solution is a method of treating LPS by forming puncture pancreaticogastroanastomosis. A flexible metal conductor was placed as close as possible to the pancreatic duct under the control of X-ray television along the fistulous tract into the pancreatic duct or into the residual cyst cavity. A device with a catheter put on was inserted as deeply as possible along a metal guide. Under the control of X-ray television, the curved end of the external cannula was oriented towards the posterior wall of the stomach. A gastroscope was inserted into the lumen of the stomach and air was insufflated. After removal of the guide wire and insertion of the mandrel, the curved needle acquired a piercing ability. Puncture of the posterior wall of the stomach was performed under the control of X-ray and gastroscopy. A flexible metal guidewire was introduced into the stomach lumen, the end of which was fixed with an endoscopic loop. Further, drainage was introduced into the lumen of the stomach. The device and conductor were removed. With the help of a thread, the distal end of the drainage was folded in the lumen of the stomach, after which the catheter was fixed on the skin. In the following days, the catheter was periodically retracted to maintain the pressure of the distal end of the drainage on the posterior stomach wall. Within 10-14 days, the distal end of the drainage migrated through the posterior wall of the stomach towards the pancreas. After that, the catheter was removed, and the external fistulous opening was closed after 1-2 days. (Ivshin V.G. Method of treating external pancreatic fistulas // Annals of surgical hepatology. - 2000. - T. 5. - No. 2. - P. 177; Ivshin V.G. Method of treating external pancreatic fistulas // Annals of surgical hepatology .- 2005. - Volume 10.- No. 3. - S. 101-107.).

However, this method is not applicable in the case of gastrectomy or gastric resection; for its implementation, the assistance of the endoscope from the gastric lumen is required. In addition, this method is performed through the pancreatic duct; The method provides for the removal of alkaline pancreatic juice into the stomach, where it is neutralized by the acid of the gastric juice, and therefore, in the postoperative period, it is necessary to take enzymes that compensate for this reaction.

Thus, from the prior art, no methods have been identified for forming anastomoses of a pancreatic fistula with a duodenum, which are the most physiological variant of pancreatic juice diversion, close to the natural anatomical.

The technical problem solved by the claimed invention is the performance of pancreaticofistuloduodenostomy under ultrasound and fluoroscopic guidance with endoscopic control for the treatment of LPS in patients without a stomach or with a resected stomach, in which the duodenum is disconnected.

Disclosure of the essence of the invention

The technical result is to reduce the trauma of manipulation and reduce the duration of hospitalization, the formation of a physiological variant of pancreatic juice diversion, which ensures the cure of patients with external pancreatic fistulas, which, for various reasons, cannot perform endoscopic stenting of the Wirsung duct, it is impossible to form an anastomosis between the fistula and the stomach. The method is physiological, because pancreatic juice is discharged into the duodenum and it is involved in digestion and its regulation. Distinctive features of the proposed method is also the possibility of its implementation without endoscopic assistance. In addition, the method is based on disconnecting the duodenum from the passage of food.

The technical result is achieved when implementing a method for treating an external fistula of the proximal pancreas after gastrectomy or resection of the stomach includes the introduction of a catheter into the fistulous passage and the duodenum, according to which a stylet-catheter with a needle is inserted under ultrasound control along the fistulous passage and the medial catheter is pierced as close as possible to the pancreas the wall of the duodenal stump, the stylet is removed, a contrast agent is injected through the needle to control the needle entering the lumen of the duodenal stump, then through the needle into the lumen of the duodenum, along the lower horizontal branch of the intestine behind Treyz's ligament, a conductor is inserted, the needle is removed, the conductor is carried out bougienage of the fistulous canal and the duodenal wall to the size of the drainage tube with lateral holes, then install a drainage tube with side holes along the conductor so that part of the holes is in the fistulous canal, and some in p In the light of the duodenum, fistulography is performed to control the standing of the drainage tube, while the drainage tube is fixed to the skin, after a day it is closed and, not earlier than 14 days later, removed.

During the treatment, it is possible to carry out X-ray television control of the position of the end of the needle in the lumen of the duodenum with a radio-opaque substance in the cavity of the duodenum.

Brief Description of Drawings

The invention is illustrated by illustrative material, where in FIG. 1-5 shows a diagram of the drainage tube in the duodenum lumen.

Implementation of the invention

Percutaneous perforation of the medial wall of the duodenum is performed retrograde along the canal of the external pancreatic fistula using a drainage tube with a fixing thread with a diameter of at least 12 Fr. In this case, the drainage tube is removed no earlier than 14 days after the formation of the anastomosis between the pancreatic fistula and the duodenum 12. The method makes it possible to expand the therapeutic possibilities in the treatment of external pancreatic fistulas.

Under ultrasound guidance (any available ultrasound diagnostic apparatus is used) along the fistulous course with a stylet-catheter as close as possible to the pancreas, the medial wall of the duodenum is punctured to the lumen (Fig. 1, 2). The stylet is removed. Under X-ray television control (any available C-arm is used) contrast is produced in the duodenal cavity in order to make sure that the end of the needle is in the duodenum. A guidewire is inserted into the needle along the lower horizontal branch of the intestine behind the Treitz's ligament, and the drainage canal and the duodenal wall are bougiened using the guidewire using the Seldinger technique to the size of the drainage tube being installed (Fig. 3). Next, a drainage tube with perforated lateral holes is installed along the conductor, so that some of the holes are in the fistulous canal, and some are in the duodenum (Fig. 4, 5). Fistulography is performed to assess the standing of the drainage tube, if necessary, its position is corrected. The drainage tube is fixed to the skin. For a day, the drainage tube remains on its own, after which the drainage is closed. The drainage tube is removed no earlier than 14 days later.

The invention is illustrated by clinical examples.

Example. 1 Patient L., 67 years old. Anamnesis: in 2011, the patient underwent gastrectomy with Billroth II reconstruction, splenectomy for stomach cancer. In 2018, the patient suffered from pancreatic necrosis of the head of the pancreas with abscess formation, for which percutaneous drainage was performed. In the outcome of the disease, the patient developed an external pancreatic fistula. The debit of pancreatic juice was up to 700 ml per day. It was not possible to perform endoscopic stenting of the pancreatic duct due to previous surgery. Conservative methods for closing an external pancreatic fistula, including long-term antisecretory therapy (octreotide), were ineffective.

With X-ray fistulography, when a contrast agent is injected into a tube, the contrast enters the fistula and immediately into the pancreatic duct in the region of the pancreatic head. The pancreatic duct is contrasted along the entire length, the contours are even, clear, there is a partial flow of contrast agent into the lumen of the duodenum (duct stenosis in the region of the pancreatic head).

During ultrasound examination of the abdominal organs, a drainage tube is located, the end of which is located in the projection of the head of the pancreas. The stump of the disconnected duodenum is intimately attached to the walls of the fistulous passage and the distal end of the tube. No echo signs of free and delimited liquid accumulations were found.

Operation: under endotracheal anesthesia, puncture pancreaticoduodenostomy was performed under ultrasound guidance and X-ray television control. A 14 Fr radiopaque drainage tube with a retaining ring was installed. The drainage tube is left to drain.

Postoperative period: a day later, the drainage tube is closed. X-ray fistulography was performed on the 14th day after the operation. When a contrast agent is injected into the tube, the lumen of the small intestine is immediately performed, the previously detected cavity and pancreatic duct are not contrasted. The drain tube has been removed. A control ultrasound examination revealed no echo signs of free and delimited fluid accumulations. The patient was discharged in a satisfactory condition on the 16th day after the operation after the complete elimination of the fistula.

Example 2 Patient B., 55 years old. Anamnesis: in 1980 he underwent gastric resection with Billroth II reconstruction for a giant peptic ulcer of the stomach. In August 2018, the patient underwent acute severe pancreatitis, total pancreatic necrosis in the region of the pancreatic head. The patient underwent percutaneous drainage of the bursa. Was discharged with a formed external pancreatic fistula. The debit of pancreatic juice was 500 ml per day. It is not possible to perform endoscopic stenting of the pancreatic duct due to previous surgical intervention. Conservative methods for closing an external pancreatic fistula, including antisecretory therapy (octreotide), were ineffective.

With X-ray fistulography, when a contrast agent is injected into a tube, the contrast enters the fistula and into the distal portion of the pancreatic duct through a defect in the isthmus of the pancreas. Discharge of contrast into the duodenum was not obtained. The main pancreatic duct is contrasted in the distal part, its contours are even, clear. The proximal part of the pancreatic duct is not contrasted, the discharge of the contrast agent into the duodenum lumen was not revealed (complete absence of the lumen of the pancreatic duct in the head region due to total necrosis of the pancreas body).

During ultrasound examination of the abdominal organs, a drainage tube is located, the end of which is located in the projection of the isthmus of the pancreas. The stump of the disconnected duodenum is adjacent to the walls of the fistulous passage. No echo signs of delimited liquid accumulations were found.

Operation: under endotracheal anesthesia, puncture pancreaticoduodenostomy was performed under ultrasound guidance and X-ray television control. A straight 14 Fr radiopaque drainage tube was inserted with a straight distal end inserted behind Treitz's ligament. The drainage tube is left to drain.

Postoperative period: a day later, the drainage tube was closed. On the 14th day after the operation, X-ray fistulography was performed, in which the contrast agent immediately enters the lumen of the small intestine, no leakage of the contrast agent was detected. The drain tube has been removed. There was no leakage of pancreatic juice and duodenal contents from the puncture site. A control ultrasound examination revealed no echo signs of free and delimited fluid accumulations. The patient was discharged in satisfactory condition on the 15th day after the operation.

Example. 3 Patient N., 30 years old. Medical history: in 2010, the patient underwent gastrectomy with Billroth II reconstruction for a malignant gastric ulcer. In June 2018, he was hospitalized at the N.N. N.V. Sklifosovskiy for acute severe pancreatitis, large-focal pancreatic necrosis, for which drainage, redraining of pancreatogenic destruction zones under X-ray television (RTV) guidance were performed. In the outcome of the disease, the patient developed an external pancreatic fistula. The debit of pancreatic juice was up to 250 ml per day. It is not possible to perform endoscopic stenting of the pancreatic duct due to a previous operation. A course of antisecretory therapy (octreotide) was carried out, a decrease in the debit of pancreatic juice to 100 ml was noted. The fistula did not close completely.

With X-ray fistulography, with the introduction of a contrast agent into the tube, its lumen is performed, at a distance of up to 4.0 cm from the proximal end, a small rounded cavity is contrasted, closely adjacent to the upper contour of the drainage tube. Further, through a filamentous passage 2 cm long, the Wirsung duct is contrasted, the discharge of the contrast agent into the duodenum is not noted - a complete break of the Wirsung duct. No communication of the cavity with the free abdominal cavity was revealed. During ultrasound examination of the abdominal organs, a drainage tube is located, the end of which is located in the projection of the isthmus of the pancreas, a hypoechoic zone of about 3.4 × 1.3 cm is located nearby. The stump of a disconnected duodenum is intimately attached to the walls of the fistulous tract. The pancreatic duct is not located. No echo signs of free and delimited liquid accumulations were found.

Operation: under endotracheal anesthesia, puncture pancreaticoduodenostomy was performed under ultrasound guidance and X-ray television control. A 14 Fr drain tube with a retaining ring was installed. The drainage tube is left to drain.

Postoperative period: on the 2nd day, the drainage tube was closed. There was a slight leakage of pancreatic juice and duodenal contents through the drainage canal for 10 hours. There was no hyperthermia. In the department, the patient underwent analgesic, antispasmodic therapy. X-ray fistulography was performed on the 6th day after the operation. When a contrast agent is injected into the tube, the previously detected cavity and pancreatic duct are not contrasted, no leakage of the contrast agent was detected. On the 14th day after the operation, the drainage tube was removed. There was no leakage of pancreatic juice and duodenal contents from the puncture site. A control ultrasound examination revealed no echo signs of free and delimited fluid accumulations. The patient was discharged in satisfactory condition on the 16th day after the operation.

Example 4 Patient M., 42 years old. Anamnesis: in 1992, the patient underwent subtotal gastrectomy with Billroth II reconstruction for cancer of the antrum of the stomach, recurrent arterial jet bleeding. In November 2018, she underwent acute severe pancreatitis, subtotal hemorrhagic pancreatic necrosis, for which percutaneous drainage and transfistular sanitization of pancreatogenic destruction zones were performed under the control of X-ray television. In the outcome of the disease, the patient developed an external pancreatic fistula. The debit of pancreatic juice was up to 120 ml per day. It was not possible to perform endoscopic stenting of the main pancreatic duct due to previous surgery. Conservative methods of closing an external pancreatic fistula (antisecretory therapy) were ineffective. With X-ray fistulography, with the introduction of a contrast agent into the tube, a cavity is made in the projection of the drainage tube of an irregular shape with indistinct irregular contours measuring 3.4 × 2.6 cm.

the lower contour of the cavity departs a short fistulous passage up to 1.0 cm long and up to 0.4 cm wide, which, when tightly filled, communicates with the pancreatic duct in the region of the pancreatic head, no discharge of contrast agent into the duodenum lumen was detected (stenosis in the large duodenal papilla). Messages with a free abdominal cavity were not identified.

Operation: under endotracheal anesthesia, puncture pancreaticoduodenostomy was performed under ultrasound guidance and X-ray television control. A straight 14 Fr radiopaque drainage tube was inserted with a straight distal end inserted behind Treitz's ligament. The drainage tube was left to drain.

Postoperative period: after 1 day, the drainage tube was closed. No leakage of pancreatic juice and duodenal contents through the drainage canal was observed. There was no hyperthermia. In the department, the patient underwent antispasmodic therapy. X-ray fistulography was performed on the 14th day after the operation. When a contrast agent is injected into the tube, the lumen of the small intestine is performed, the previously detected cavity and pancreatic duct are not contrasted. The drain tube has been removed. There was no leakage of pancreatic juice and duodenal contents from the puncture site. A control ultrasound examination revealed no echo signs of free and delimited fluid accumulations. The patient was discharged in satisfactory condition on the 17th day after the operation.

Example. 5 Patient G., 60 years old. Anamnesis: In 2010, the patient underwent video laparoscopic gastrectomy with Billroth II reconstruction for stomach cancer. In December 2017, he suffered acute severe pancreatitis, large-focal pancreatic necrosis. The patient underwent multiple percutaneous drainage, redraining of pancreatogenic destruction zones, and transfistular debridement. In the outcome of the disease, the patient developed an external pancreatic fistula. The debit of pancreatic juice was up to 400 ml per day. It is impossible to perform endoscopic stenting of the pancreatic duct due to a previous operation. Long-term antisecretory therapy (octreotide) proved to be ineffective. With X-ray fistulography, when a contrast agent is injected into a tube, a fistulous passage is performed, then the contrast agent enters the pancreatic duct in the region of the pancreas head. The pancreatic duct is contrasted throughout. During ultrasound examination of the abdominal organs, a drainage tube is located, the end of which is located in the projection of the head of the pancreas. No echo signs of free and delimited liquid accumulations were found.

Operation: under endotracheal anesthesia, puncture pancreaticoduodenostomy was performed under ultrasound guidance and X-ray television control. A 14 Fr radiopaque tube was installed with a straight distal end inserted behind the Treitz ligament. The drainage tube was left to drain.

Postoperative period: a day later, the drainage tube was closed. Within 12 hours from the moment of surgery, there was a leakage of pancreatic juice and duodenal contents through the drainage canal. There was no hyperthermia. In the department, the patient underwent analgesic therapy. X-ray fistulography was performed on the 8th day after the operation. When a contrast agent is injected into the tube, the lumen of the small intestine is immediately performed, no leakage of the contrast agent was detected. The drainage tube was removed on the 14th day. Leakage of pancreatic juice and duodenal contents from the puncture site was not observed. A control ultrasound examination revealed no echo signs of free and delimited fluid accumulations. The patient was discharged in satisfactory condition on the 15th day after the operation.

Thus, the claimed method provides physiological treatment of an external fistula of the proximal pancreas without the assistance of endoscopy, when the duodenum is disconnected from the passage of food, in which the pancreas juice is diverted into the duodenum and participates in digestion and its regulation. The invention reduces the trauma of surgical treatment and reduces the duration of hospitalization.

Claims (2)

1. A method of treating an external fistula of the proximal pancreas after gastrectomy or resection of the stomach with reconstruction according to Billroth II, including the introduction of a catheter into the fistulous tract and duodenum, characterized in that under ultrasound control, a stylet-catheter with a needle is inserted into the fistulous tract and the medial the wall of the duodenal stump, the stylet is removed, a contrast agent is injected through the needle to control the needle entering the lumen of the duodenal stump, then through the needle into the lumen of the duodenum, along the lower horizontal branch of the intestine behind Treyz's ligament, a conductor is inserted, the needle is removed, the conductor is carried out bougienage of the fistulous canal and the duodenal wall to the size of the drainage tube, then a drainage tube with lateral holes is installed along the guidewire so that part of the holes are in the fistulous canal, and part in the duodenal lumen, fistulography is performed to control one hundred the drainage tube, while the drainage tube is fixed to the skin, in a day it is closed and, not earlier than in 14 days, it is removed. 2. The method according to claim 1, characterized in that X-ray television control of the position of the needle tip in the duodenal lumen with a radio-opaque substance in the duodenal cavity is carried out.

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