RU2749983C1 - Method for sealing pancreato-intestinal anastomosis using fibrin composite - Google Patents

Abstract

FIELD: abdominal surgery.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. First, the back, then the front lips of the pancreato-intestinal anastomosis are formed with atraumatic suture material in one row. On the anterior and posterior lips of the anastomosis, cryoprecipitate of human blood plasma of the same group as the operated patient is applied in a volume of 10 ml. Then a solution of thrombin is applied to it at a dose of 300 MU, diluted in 10 ml of 10% calcium gluconate in a 1:1 ratio.

EFFECT: invention increases efficiency of sealing the pancreato-intestinal anastomosis and avoids suture failure.

1 cl, 3 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used to prevent postoperative complications.

Diseases of the pancreas have a clear tendency to increase and this applies not only to pancreatic tumors, but also chronic pancreatitis (P.G. Lankisch, C. Assmus). When a pancreato-intestinal anastomosis is applied, which completes the resection of the pancreas, the likelihood of complications is high, this is due to the production of enzymes, as well as the morphological structure of the pancreatic tissue. Most often, the sutures in the tissue of the pancreas are cut or melted. The problem of improving and sealing the pancreato-intestinal anastomosis seems to be relevant.

A known method of sealing the pancreato-intestinal anastomosis by imposing isoperistaltic pancreatojejunostomy during Frey's operation, so that the closed blind end of the intestinal loop is directed towards the tail of the gland and adjoins it. Anastomosis is formed with interrupted sutures. When the anastomosis is formed with two-row interrupted sutures, the first posterior row of interrupted sutures captures the serous-muscular membrane of the intestine and the tissue of the pancreas together with its peritoneal cover. After imposing the back row of sutures of the pancreatojejunostomy, the intestine is cut longitudinally along a length corresponding to the length of the gland incision. The second row of interrupted sutures is carried out through all layers of the jejunum and the edge of the dissected gland, without trying to capture the mucous membrane of the duct into the suture (this is permissible only with cystic enlargement of the duct). Further, observing the described technical conditions, two rows of interrupted sutures are applied to the anterior lip of the anastomosis (Danilov M.V., Fedorov V.D. Pancreatic surgery: A guide for doctors. - M .: Medicine, 1995.512 p: p: 310 -322).

However, the known method has a disadvantage, since when a two-row suture is applied between the intestine and the resected pancreas, a deficiency of the intestinal wall often occurs. This occurs in cases when intraparenchymal resection is performed with the divergence of the edges of the resected pancreas, or in cases where the intestine has a small diameter, then the second row of sutures is applied with tissue tension, which subsequently leads to the eruption of the suture.

The closest to the achieved technical result, the prototype is a method of sealing the pancreato-intestinal anastomosis, which consists in local resection of the head of the pancreas with lateral pancreaticojejunostomy or longitudinal pancreatoenterostomy with resection of the pancreas according to Frey. The abdominal cavity is entered through the upper midline laparotomy. Examine the abdominal organs to exclude other pathology. The gastro-colonic ligament is dissected and entered into the omental bursa.

First, the tissue of the gland is dissected to the duct. The volume of excision of the head of the pancreas is progressively increased, starting along the open proximal part of the pancreatic duct. The volume of excision of the head can be increased due to the previously isolated superior mesenteric and portal veins, without fear of injury to these venous structures.

A Y-shaped small bowel loop is created along Roux with a length of 60 cm. It is passed through an opening in the mesentery of the transverse colon and a side-to-side pancreatoenteroanastomosis is applied to it. First, the inferior posterior wall of the anastomosis is created with single Lamber sutures with capron No. 3/0. Then create an internal continuous winding sealing suture with absorbable synthetic thread No. 3/0, continuing along the front wall of the anastomosis according to the method of O. Connelly (Littmann I. Abdominal surgery. - Budapest, 1970 - 564 pages).

The front wall is closed with a continuous single-row suture with atraumatic thread No. 3. Tubes of two silicone plastic drainages connected to a closed aspiration system are brought to the pancreaticojejunostomy. From the abdominal cavity, drains are removed through puncture wounds in the upper left quadrant of the abdominal wall. The branch of the U-shaped anastomosis according to Roux is fixed to the edges of the opening in the mesentery of the transverse colon (Atlas of Operative Gastroenterology / John L. Cameron, Corinne Sandon; translated from English. Edited by A.S. Ermolov. - M .: GEOTAR-Media, 2009 .-- 560 s. Pp. 277-283).

However, the known method has disadvantages, first of all, it concerns the injection into the tissue of the pancreas, if the tissue of the gland is loose, then cutting of the thread can be expected due to the release of its enzymes and inflammation. A single-row suture becomes leaky due to an inflammatory process in the tissue of the pancreas, and in cases of cystic accumulation or abscess concomitant with chronic pancreatitis or an abscess along the upper edge of the gland, the risk of failure of the pancreto-intestinal anastomosis increases.

The authors propose a method for sealing the pancreato-intestinal anastomosis by using a special sealing compound, which allows for the prevention of suture incompetence.

The technical result of the proposed method is to increase the efficiency of sealing the pancreato-intestinal anastomosis after resection of the pancreas.

The technical result is achieved by the fact that a special sealing compound is applied to the seam area of the pancreaticintestinal anastomosis, which includes two components.

The first component is a cryoprecipitate of blood plasma of the same group with a volume of 10 ml for the operated patient.

The second component includes a human thrombin preparation at a dose of 300 IU, which is dissolved in 10 ml of 10% calcium glucanate solution in a 1: 1 ratio. Plasma cryoprecipitate contains a high concentration of fibrinogen. Thrombin interacts with fibrinogen to form fibrin. The formed fibrin seals the suture area, including the puncture from the needle. The fibrin film initially looks like a gelatinous mass. And subsequently, as shown by experimental studies in the area of the suture, additional fibrous tissue appears that seals the anastomosis.

Additional fibrin produces biological sealing of the anastomosis. When it ripens, it prevents the destruction of the anastomosis by tissue enzymes.

The method is illustrated by Figures 1, 2, 3.

Figure 1 shows an image of a pancreato-intestinal anastomosis.

Figure 2 shows the application of the components of the fibrin composite.

Figure 3 shows the final view of the proposed method.

The method is carried out as follows.

An upper-median laparotomy is performed, and Sigal retractors are installed. After revision of the abdominal organs, release from possible adhesions and adhesions, access is performed through the gastro-colonic ligament. The pancreas is mobilized. Puncture of the main pancreatic duct is performed. The altered tissue of the pancreas is excised. A local resection of the head and body of the pancreas is done according to Frey.

Departing from the Treyz ligament 30-40 cm, an intestinal loop 60 cm long is mobilized and switched off according to Roux. The loop is moved into the omental bursa through the window in the mesentery of the mesocolon.

Fixing sutures of the first row are applied between the intestinal loop and the capsule of the pancreas, after which the intestinal loop is opened for the length necessary for the imposition of the anastomosis, retreating 3 cm from the plugged end of the intestinal loop. A continuous suture is placed between the tissue of the pancreas and the dissected intestinal wall using atraumatic material (Fig. 1).

After that, a cryoprecipitate of blood plasma of the same group with the operated patient in a volume of 10 ml is applied to the anterior and posterior lips of the anastomosis. Then a solution of thrombin at a dose of 300 IU diluted in 10 ml of 10% calcium glucanate in a 1: 1 ratio is applied to it with a syringe drops. (Fig. 2). After 20-30 sec. In the area of the anastomosis, a gel appears covering the entire anastomosis and the area of injections of the intestinal needle (Fig. 3).

The claimed method treated 41 patients. The method allows to prevent such a formidable complication as the occurrence of insolvency of the pancreato-intestinal anastomosis in the early postoperative period and can be used for resection of the pancreas, in complicated cases.

Clinical example:

Patient A., 37 years old, was admitted to the clinic with complaints of recurrent pain in the epigastrium, aching in nature, weight loss.

He considers himself a patient since 2016, when he first noted the appearance of pain in the epigastrium, received treatment for acute pancreatitis c. Was discharged in satisfactory condition, the pain attack was arrested. Upon further examination, a cyst was found in the head of the pancreas in 2017, he was treated in the department of purulent surgery of the KKB with a diagnosis of Postnecrotic parapancreatic cyst. Drainage of the cyst under the EUS, bleeding from the cyst. 07/31/17 performed laparotomy, intraoperative hemostasis, debridement, drainage. The last hospitalization in the Central District Hospital with an exacerbation of pancreatitis on 15.11.18, received conservative treatment. Examined by the ACKP surgeon, sent for hospitalization for surgical treatment in the surgical department of the KKB.

With an objective examination.

The general condition is satisfactory. Consciousness is clear, the position is active. The physique is correct, reduced nutrition. Skin and visible mucous membranes of normal color. Peripheral lymph nodes are not enlarged. No edema. The rib cage is formed correctly, both halves symmetrically participate in the act of breathing. Percussion clear pulmonary sound over all pulmonary fields, with auscultation vesicular breathing, no wheezing. NPV 17 per minute. The heart sounds are muffled, the rhythm is correct. Rhythmic pulse, good filling 70 / min. BP - 120/80 mm Hg The area of the bladder and kidneys without deformation, hyperemia, no edema. The lumbar region is not edematous, symmetrical. Painless on palpation. The kidneys are not palpable. The tapping symptom is negative on both sides. Status localis: Tongue moist, partially overlaid with white bloom. The abdomen is symmetrical, not swollen, participates in the act of breathing. A scar after a midline laparotomy, moderate soreness in the epigastrium. Liver along the edge of the costal arch. The spleen is not palpable. There are no symptoms of abdominal irritation.

Ultrasound of the abdominal cavity from 11/26/18: Volumetric formation of the pancreas (cyst?). Nonspecific changes in the structure of the liver. A small amount of free fluid in the abdominal cavity.

MSCT of the abdominal organs from 11/27/2018 - Pancreas: the contours are quite clear, lobular structure, an oval hypodense formation in the head area is determined, measuring 47 × 69 × 50 mm, with a thin capsule of 2 mm. Parapancreatic fiber is not changed. Conclusion: Enlargement of the right lobe of the liver. Pancreatic head cyst.

FGDS from 11/29/2018: Conclusion: Chronic gastrobulbitis.

12/04/18 after preliminary preoperative preparation, the operation was performed: resection of the head of the pancreas, cyst wall, pancreatoenteroanastomosis in the intestinal loop turned off according to Roux, cholecystectomy.

During the operation: The head of the pancreas is significantly enlarged due to a cyst of dense elastic consistency, 8 × 7 cm. The body and tail of the gland are sealed. In the area of parapancreatic tissue and hepatoduodenal ligament, there is a cicatricial periprocess. A loop of the duodenum with the head of the pancreas was isolated from the adhesions, mobilized according to Kocher. The anterior surface of the pancreas head was highlighted, the omental bursa was opened - sealed. The anterior surface of the head and isthmus of the gland are the wall of the cyst.

Intraoperative ultrasound was performed: in the area of the pancreatic head, an anechoic avascular mass with a suspension of up to 1/3 of the lumen measuring 60 × 41 mm, the body and tail of the pancreas with preserved lobulation, moderate echogenicity. Wirsung duct up to 2 mm.

The cyst was opened, 150 ml of turbid serous fluid (pancreatic juice) with crumbs was removed. Revision: the cyst has an irregular shape, occupies almost the entire head of the pancreas. The walls of the cyst are uneven, with fibrin, contact bleeding. The anterior surface of the head of the pancreas was dissected to the isthmus, the anterior wall of the cyst was excised to the glandular tissue. At the bottom of the cyst cavity, a pancreatic duct opens into the lumen, from which pure pancreatic juice flows. The mouth of the duct on the probe is dissected by 1 cm. Hemostasis by coagulation. A Roux-Mobilized loop of the small intestine 60 cm long was passed through a window in the mesentery of the mesocolon. Imposed pancreatoenteroanastomosis with a continuous suture thread PDS 3/0 with the walls of the cyst and pancreatic tissue, single row. The anastomosis line was treated with fibrin composite. The first component - cryoprecipitate of blood plasma of the same group with the operated patient in a volume of 10 ml - was applied to the suture area of the pancreaticintestinal anastomosis. Then, on the suture area of the pancreatic anastomosis, the second component is applied including the drug - human thrombin at a dose of 300 IU, dissolved in 10 ml of 10% calcium glucanate solution. After 20-30 sec. In the area of the anastomosis, a gel formed covering the entire anastomosis and the area of injections of the intestinal needle.

The postoperative period was uneventful. The pains disappeared on the 5th day, began to eat, the passage through the intestines was restored.

Histological diagnosis - chronic pancreatitis from 13.12.2018.

OAK dated 13.12.2018: Er 4.5 × 1012 / l; platelets 210 × 109 / l; HB 142 g / l; L 7.0 × 109 / l, ESR-32 mm / h.

Biochemical blood test from 13.12.2018: amylase 65.5 U / l; about. bilirubin 14.8 μmol / l; creatinine 89.9 μmol / l; urea 6.55 mmol / l; about. protein 79.3 g / l; glucose 5.58 mmol / l.

Discharged with recovery. Control examination after 3 months. There are no complaints at the time of inspection. The condition is satisfactory. Follows a diet, works.

Thus, the claimed method is highly effective and avoids the failure of the seams of the pancreato-intestinal anastomosis and can be used in the complicated course of chronic pancreatitis.

Claims (1)

A method of sealing a pancreato-intestinal anastomosis using a fibrin composite, including a local resection of the head and body of the pancreas according to Frey with a longitudinal pancreatoenterostomy, characterized in that first the posterior, then the anterior lips of the pancreato-intestinal anastomosis are formed with atraumatic suture material in one row the posterior lip of the anastomosis is applied cryoprecipitate of human blood plasma of the same group as the operated patient in a volume of 10 ml, then a solution of thrombin at a dose of 300 ME, diluted in 10 ml of 10% calcium gluconate in a ratio of 1: 1, is applied to it.

Images