RU2736006C2 - Method for draining the small intestine loop involved in the formation of pancreato-jejunoanastomosis and cholangio-jejunoanastomosis after pancreaticoduodenal resection - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to oncology, surgery. Form small intestine loops according to Roux, lateral-to-end pancreato-jejunoanastomosis and end-to-side hepatico-jejunoanastomosis are formed. Drainage is performed in a lumen of the small intestine lumen on which the listed anastomoses are formed, and the drainage is delivered to the skin through a counter-operative in the form of suspended enterostomy. Drainages of Wirsung's duct and hepatico-jejunoanastomosis are brought out separately through the same loop.EFFECT: method is easy to reproduce, well tolerated, safe, allows most patients to reduce number of anastomosis inconsistencies and promotes early activation of patients in postoperative period.1 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, in particular to oncology, surgery. The method allows to reduce the frequency of clinically significant incompetence of pancreato-jejunostomy by decompression of the loop of the small intestine involved in the formation of the anastomosis.

Pancreatic cancer is still an acute problem in domestic and foreign oncology. The detection of these tumors in the initial stage ranges from 10 to 30%, and radical treatment is possible up to 10% of patients. For example, in the United States, more than 29,000 cases of pancreatic adenocarcinoma are diagnosed every year. Of these patients, only 10–20% have resectable tumors, and 25,000 (83%) patients die within 12 months. after diagnosis. Mortality from pancreatic cancer in Russia among men is 10.7, among women - 8.7 per 100 thousand.In the structure of mortality of the Russian population from malignant tumors in 2019, the relative frequency of pancreatic cancer in men is 4.6% (6 place), among women - 5.1% (7th place) [Kaprin A.D. 2019]. Moreover, the surgical method is the main one in the treatment of localized pancreatic cancer. Pancreatoduodenal resection (PDR) in the Russian Federation remains a rare operation, although the real need for it for pancreatic tumors is very high. According to publications in the literature, we can say that radical surgical treatment is performed in a smaller proportion of patients for whom this treatment is indicated. The main reason for a wary attitude towards pancreatoduodenal resection is a large number of complications, usually anastomoses failure

The method of pancreatoduodenal resection (RU 2166289 C2) is adopted as a prototype of the present invention. The pancreatojejunoanastomosis is applied end to the side with the initial part of the jejunum, then gastrojejunoanastomosis is applied according to the Hofmeister-Finsterer method on the abduction knee of the proximal loop of the jejunum 30 cm from the pancreatojejunoanastomosis with the initial part of the jejunum 70 from the stump of the jejunum with interintestinal Brownian anastomosis.

However, when using this method, the loop of the small intestine, with which all anastomoses are formed, is not drained, which increases the number of postoperative failures of pankeatojejuno choledochojejunoanastomoses

The technical result of the proposed invention is to reduce the incidence of pancreatojejuno and hepaticojejunoanastomoses due to drainage of the loop carrying them by bringing the drainage outward.

The peculiarity of the proposed method is that the loops of the small intestine along Roux are formed, pancreato-jejunoanastomosis "side-to-end" and hepatico-jejunoanastomosis "end-to-side", drainage is carried out into the lumen of the loop of the small intestine, on which the listed anastomoses are formed, and drainage is removed on the skin through a counterperture in the form of a suspended enterostomy, then through the same loop, drainages of the Wirsung duct and hepaticojeunoanastomosis are brought out separately.

The invention is illustrated by a detailed description, a clinical example and illustrations, which depict:

FIG. 1 - View of the operating field after performing pancreatoduodenal resection: the head and part of the pancreas body and duodenum are removed, the Virung duct is visualized (circled).

FIG. 2 - The stage of the formation of a pancreato-jejunoanastomosis laterally to the end. Drainage is introduced into the loop of the small intestine (drainage is circled). External drainage has been introduced into the Virsungov channel (marked with an arrow).

FIG. 3 - Pancreato-jejunoanastomosis end-to-side formed (the anastomotic zone is circled .

FIG. 4 - Drainage from the supporting loop of the small intestine is brought out to the skin through a counterperture in the form of a suspended enterostomy (the area is circled), and drainage from the Wirsung duct and drainage from the common hepatic duct are also brought out through this loop of the intestine.

The method is carried out as follows.

The resection stage of the operation is performed in the volume of pancreato-duodenal resection and the reconstructive stage: the formation of a loop of the small intestine according to Roux is performed, the formation of a small intestinal-pancreatic anastomosis by the side-to-end technique, the formation of hepatic-jejunoanastomosis end-to-side, drainage into the lumen of the loop of the small intestine, on which the listed anastomoses are formed and the drainage is brought out to the skin through a counterperture in the form of a suspended enterostomy. Also, external drainage is installed in the Wirsung duct, and is separately performed for hepatico-jejunoanastomosis.

In the postoperative period, the patient is routinely managed with control of the discharge along the drains, X-ray control of the drains for 1 day and before discharge. Drains are removed within 1 month after the operation.

Clinical example.

Patient S., born in 1954 was admitted to the clinic on 02/12/2020. Diagnosis at admission: C25 Cancer of the head of the pancreas cT1N0M0, stage IC, class II. Group.

CT scan of the chest and abdominal cavity organs with IV contrast: In the projection of the pancreatic head, a tumor up to 2 cm in size is determined, without leaving the pancreas. CT data for metastatic lesions of the chest, liver, spleen were not obtained.

Treatment was performed: pancreatoduodenal resection, drainage of the supporting loop of the small intestine. The patient was transported to the operating room of the abdominal department. Upper midline laparotomy was performed under combined endotracheal anesthesia with artificial ventilation. During revision the liver was unremarkable, serous membranes were not changed. In the head of the pancreas, a tumor of a stony density up to 2 cm in size is determined. Data for the involvement of adjacent structures in the tumor was not obtained. Performed mobilization of the duodenum 12 with the head of the pancreas, performed a resection stage in the amount of pancreato-duodenal resection. Reconstructive stage: a loop of the small intestine along Roux was formed, pancreato-jejunoanastomosis was formed by the side-to-end technique, hepatico-jejunoanastomosis was formed end-to-side, drainage was carried out into the lumen of the loop of the small intestine, on which the listed anastomoses were formed and brought to the skin through counterperture in the form of a suspension enterostomy. Also, external drainage was installed in the Virsunga duct, and separately carried out for hepaticojejunostomy, the drainages were brought out through the suspended enterostomy. Hemostasis was performed. A drain is installed in the operation area. The laparotomic wound was sutured in layers.

In the postoperative period, the patient underwent usual management with control of the discharge along the drainage, X-ray control of the drainage for 1 day and before discharge.

The postoperative period was uneventful. On day 2, the patient was activated, transferred to the department from the ICU, got up, took liquid food. The drainage from the resection area was removed on the 4th day. The beginning of peristalsis on the 3rd day. The chair was gone for 5 days. The patient was discharged in satisfactory condition on the 9th day.

Removal of drains from the loop of the intestine, Wirsung's duct and common hepatic duct was performed within 1 month after the operation.

Thus, the proposed method made it possible to reduce the number of anastomotic leaks, perform the required amount of surgical intervention for pancreatic tumors with minimization of the risk of postoperative complications.

The proposed method of treatment is easily reproducible, well tolerated by patients, safe, allows for the majority of patients to reduce the number of anastomoses leaks. Thanks to the proposed method, it is possible to perform the required amount of surgical intervention for pancreatic tumors with minimization of the risk of postoperative complications and promotes earlier activation of patients in the postoperative period.

Claims (1)

A method for draining a loop of the small intestine involved in the formation of pancreato-jejuno and hepatico-jejunoanastomosis after pancreatoduodenal resection, characterized in that they form small bowel loops along Roux, pancreato-jejunoanastomosis "side to end" and hepaticojeunoanastomosis "end to side" drainage into the lumen of the loop of the small intestine, on which the listed anastomoses are formed, and drainage is brought to the skin through counterperture in the form of a suspended enterostomy, then through the same loop, drainages of the Wirsung duct and hepaticojeunoanastomosis are brought out separately through the same loop.

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