RU2757632C1 - Method for pancreas transplant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, transplantology. The donor's duodenum is sutured on both sides, and arterial reconstruction of the splenic and superior mesenteric arteries is performed using a donor Y-shaped vascular insert. The recipient has an extraperitoneal approach from the symphysis laterally and upwards parallel to the inguinal ligament on the right. An area of ​​the small intestine with a length of 20 cm along Roux is turned off from digestion. An incision is made in the peritoneum with a size corresponding to the transverse size of the small intestine. Through it, the small intestine, turned off from digestion, is brought out into the wound so that its free end recedes from the peritoneum by 4 cm. A pancreatic graft (PG) is placed in the right iliac fossa along the wing of the ilium in an inverted position with the head downward, with the dorsal surface anteriorly. A venous anastomosis is formed between the PG portal vein and the recipient's right iliac vein. An arterial anastomosis is formed between the Y-shaped vascular insert and the recipient's right common iliac artery. Between the prepared duodenum of the donor and the free end of the recipient's small intestine, a side-to-side interintestinal fistula is formed. The surgical site is drained with two silicone drainage tubes placed above and below the pancreatic graft.

EFFECT: method allows preserving PG in case of its necrotic changes; allows to increase the duration of the functioning of PG and thereby increase the survival rate of patients with insulin-dependent diabetes mellitus, as well as reduce the number of insulin injections or completely abandon its intake; allows you to safely remove PG with minimal trauma in case of its dysfunction or necrotic changes, without requiring re-entry into the abdominal cavity.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, transplantology and can be used in the treatment of patients with insulin-dependent diabetes mellitus.

Currently, for patients with insulin-dependent diabetes mellitus, the only effective treatment method that allows to achieve an euglycemic state and prevent the progression of diabetes complications is pancreatic transplantation (Sutherland DE., Gruessner RW., Gruessner AC. Pancreas transplantation for treatment of diabetes mellitus. World J Surg . 2001; 25 (4): 487-496). Successful pancreatic transplantation can significantly improve the quality and duration of patients' life (Samoylova ML, Borle D, Ravindra KV. Pancreas Transplantation: Indications, Techniques, and Outcomes. Surg Clin North Am. 2019; 99 (1): 87-101).

A pancreatic transplant (PTG) can be obtained from a posthumous donor, as well as from a living related donor in the form of a pancreatic segment (Sutherland DE, Goetz FC, Najarian JS. Living-related donor segmental pancreatectomy for transplantation. Transplant Proc. 1980; 12 (4 Suppl 2): 19-25).

From a surgical point of view, the actual problems of pancreas transplantation, regardless of the type of transplant - organ or segment, remain the problem of maintaining a fully functioning transplant and the problem of preventing purulent complications.

The cause of first-order problems is a violation of the trophism of the transplanted organ due to insufficient and non-physiological blood supply, followed by its dysfunction and / or destruction. Up to 10% of patients in the early stages after surgery lose the graft if it is dysfunctional due to the occurrence of vascular complications, such as arterial or venous thrombosis (Farney AC, Rogers J, Stratta RJ. Pancreas graft thrombosis: Causes, prevention, diagnosis, and intervention. Current Opinion in Organ Transplantation. 2012; 17: 87-92).

The reasons for second-order problems include the failure of the sutures of the duodenal anastomosis, which occurs in 5-8% of cases, and, as a result, intra-abdominal infectious complications, often requiring repeated surgery up to removal of the graft (Humar A, Kandaswamy R, Granger D, Gruessner RW , Gruessner AC, Sutherland DE. Decreased surgical risks of pancreas transplantation in the modern era. Annals of Surgery. 2000; 231 (2): 269-275). Problems of this kind are due to the fact that today, in most transplant centers, the technique of intra-intestinal secretion of PTG is used with a predominantly intra-abdominal variant of graft placement.

The emergence of these problems leads not only to unsatisfactory results of pancreas transplantation, but also, to a certain extent, exacerbates the issue of the deficit of donor organs.

The proposed invention will allow for reliable prevention of intra-abdominal purulent and inflammatory complications, will significantly improve the results of pancreatic transplantation.

The known "Method for segmental pancreatic transplantation" (RF patent No. 2311135 dated November 27, 2007), including the collection of the distal segment of the pancreas from the donor, its conservation and transplantation to the recipient with the provision of venous outflow from the graft into the portal vein system, characterized in that the pancreatic transplant the glands are reversed and placed with the posterior surface anteriorly, a venous anastomosis is formed with the inferior mesenteric vein at the level of the inferior horizontal branch of the duodenum, and arterial revascularization of the graft is carried out by anastomosing the proximal end of the splenic artery of the graft with the recipient aorta like the distal end to the side ligate.

The known "Method of segmental pancreatic transplantation" (RF patent No. 2311880 from 10.12.2007), including the collection of the distal segment of the pancreas from the donor, its conservation and transplantation to the recipient, characterized in that the graft is placed horizontally, retroperitoneally in the formed bed between the prerenal fascia and mesentery of the sigmoid colon, arterial revascularization of the graft is carried out by anastomosing the splenic artery of the graft with the recipient's aorta at or above the left renal vein after the latter is mobilized according to the “end-to-side” type, venous revascularization of the graft is carried out by anastomosing the splenic vein of the graft vein end to side ", then form a pancreatoenteroanastomosis, cover the graft with the root of the mesentery of the small intestine and fix it along the upper and lower edges of the graft to the prerenal fascia.

The known "Method of segmental pancreatic transplantation" (RF patent No. 2316265 dated 02/10/2008), including the collection of the distal segment of the pancreas from the donor, its conservation and transplantation to the recipient with the provision of venous outflow from the graft into the portal vein system, characterized in that the pancreatic transplant the glands are reversed and placed with the posterior surface anteriorly, a venous anastomosis of the inferior mesenteric vein is formed with the splenic vein of the graft at the level of the horizontal branch of the duodenum, and arterial revascularization of the graft is carried out by anastomosing the distal end of the splenic artery from the left common iliac artery to the end of the recipient and along the oximeter splenic artery graft with the aorta.

The known "Method of segmental pancreatic transplantation" (RF patent No. 2316266 dated 02/10/2008), including the collection of the distal segment of the pancreas from the donor, its conservation and transplantation to the recipient, characterized in that they form a venous anastomosis of the inferior mesenteric vein with the splenic vein of the graft at the level horizontal branch of the duodenum, and arterial revascularization of the graft is carried out by anastomosing the distal end of the splenic artery with the left colon artery of the recipient in the "end-to-end" manner, while the proximal end of the splenic artery of the graft is ligated.

The above methods to a greater extent reflect the originality of vascular reconstructions during transplantation of pancreatic segments. The main disadvantage of the presented methods is that the pancreatic graft is located in the abdominal cavity. Considering the fact that not a whole organ is used for transplantation, but its segment, this increases the risk of developing post-transplant pancreatitis and destruction of the graft, the occurrence of enzymatic peritonitis.

The known "Method of pancreatic transplantation with the formation of papilloduodenoanastomosis" (RF patent No. 2599376 dated 10.10.2016), including pre-transplant preparation of a pancreatic transplant, in which antiseptic treatment of the duodenal lumen is performed, vascular reconstruction, excision and formation of the site around the large and tissues of the small duodenal papillae of the duodenum by cutting off the excess intestinal wall at a distance of 2-3 cm directly from them, after which vascular anastomoses are formed between the vessels of the graft and the vessels of the recipient, as well as the intestinal anastomosis between the intestinal site of the donor and the duodenum of the recipient, while the intestinal by means of a double-row twisted or circular mechanical suture, after which the wound is drained and sutured. 2. The method according to claim 1, characterized in that after the formation of vascular anastomoses and revascularization of the pancreatic graft, the condition and blood supply of the intestinal site are assessed and, if inadequately blood supplied areas are detected, they are excised to ensure the minimum allowable distance from the papillae of 1-1.5 cm for ensuring the formation of intestinal anastomosis.

The disadvantages of the method include the complexity of techniques and a high risk of both intraoperative and postoperative complications.

The closest analogue, taken by us as a prototype, is the method described in the article "New surgical approaches to pancreas transplantation" (A.V. Pinchuk, Yu.A. Anisimov, R.V. Storozhev, I.V. Dmitriev, A. Balkarov G. New surgical approaches to pancreatic transplantation // Megalopolis Health. 2020; v. 1, no. 1: 38-50).

The authors point out that they performed pancreatic transplantation retroperitoneally in the right lateral canal, after contralateral retroperitoneal kidney transplantation. Vascular anastomoses were formed between the reconstructed graft artery and the right common iliac artery, the portal vein of the PDT, and the inferior vena cava. The graft was placed in the optimal position - the head of the gland was oriented cranially, the tail was lowered caudally. To drain exocrine secretions from the graft, a method of non-stump duodenal drainage of the button-technique type was used - an interintestinal fistula was formed between the segment of the donor duodenum and the lower horizontal part of the recipient's duodenum with a circular mechanical suture 21 mm in diameter.

The disadvantages of the described method include the following. The use of a hardware suture in the formation of the interintestinal fistula between the segment of the donor duodenum and the lower horizontal part of the recipient's duodenum undoubtedly makes it possible to shorten the operation time, but at the same time increases the risk of developing purulent complications, due to the fact that for the imposition of a hardware suture it is necessary to additionally open the duodenum lumen recipient for stapling. That is, this technique of forming an anastomosis (in contrast to the classic manual suture) presupposes the presence of two "dangerous" zones in relation to the failure of the sutures: the duodeno-duodenoanastomosis itself and the sutured duodenotomy opening. In addition, the volume of donor duodenal tissue left for the formation of an anastomosis with the recipient duodenum using the button-technique is very small in terms of tissue vascularization, which can impair the healing of the anastomosis, increasing the risk of its leakage. If such a situation arises, the exit from the recipient's duodenum of aggressive content, which contains an increased volume of pancreatic secretion due to two pancreas secreting juice, will lead to the destruction of the graft tissue and its dysfunction. Also, the disadvantage of the described technique can be attributed to the positioning of the pancreas graft, namely, the location of its head in the cranial direction with bringing down the tail caudally. Such an arrangement of the graft does not seem physiological, since when the patient is in an upright position, gravitational forces act on his body, which impedes the conditions for the outflow of pancreatic secretion into the duodenum. The accumulation inside the lumen of the pancreatic ducts rich in proenzymes and active proteins of pancreatic juice, together with an increase in intrapancreatic hydrostatic pressure, leads to the development of edema and inflammation of the graft tissues, as a result of which its dysfunction occurs.

These disadvantages are eliminated in the claimed invention.

The objective of the claimed invention is to develop a method that allows, in the event of failure of the sutures of the duodenal anastomosis or destruction of the pancreatic transplant (PTG), to prevent the spread of purulent inflammation into the abdominal cavity and eliminate these complications with a minimal risk of threatening the patient's life without removing the graft, and, if necessary, to remove the PTG, perform an operation without entering the abdominal cavity.

The task is solved by the fact that pre-transplantation preparation of TPG is carried out by suturing the donor's duodenum (DPCD) on both sides, and arterial reconstruction of the splenic and superior mesenteric arteries using a donor Y-shaped vascular insert, after which the recipient has an extraperitoneal access from the symphysis laterally and upwards parallel to the inguinal ligament on the right, the peritoneum is opened with a 6 cm incision; turn off from digestion a section of the small intestine 20 cm long according to Roux, restore the continuity of the gastrointestinal tract by forming a small-intestinal anastomosis of the "end-to-side" type, the free end of the small intestine is sutured; an additional incision of the peritoneum is made with a size corresponding to the transverse size of the small intestine, through it, the small intestine turned off from digestion is brought out into the wound so that its free end recedes from the peritoneum by 4 cm, the intestine in the area of the peritoneal incision is fixed with single interrupted sutures, the dissected peritoneum is sutured tightly ; TPG is placed in the right iliac fossa along the wing of the ilium in an inverted position with the head downward, with the dorsal surface anteriorly; according to the generally accepted technique, a venous anastomosis is formed between the portal vein of the TPV and the recipient's right iliac vein; form an arterial anastomosis between the Y-shaped vascular insert and the recipient's right common iliac artery; between the prepared DPKD and the free end of the recipient's small intestine, a side-to-side interintestinal fistula is formed; the operation area is drained with two silicone drainage tubes installed above and below the TPG; the wound is sutured in layers.

The technical result of using the proposed technique is:

- prevention of the spread of purulent inflammation into the abdominal cavity associated with destructive changes in the duodenal fluid or failure of the sutures of the duodenal anastomosis;

- prevention of involvement in the purulent-inflammatory process of the abdominal organs;

- the ability to save TPG in case of its necrotic changes;

- no need to re-enter the abdominal cavity if it is necessary to perform a transplant.

The technical result is achieved by extraperitoneal placement of TPV in the right iliac region and adequate drainage of the operation area.

Thus, the claimed method will improve the results of pancreas transplantation by preventing the spread of purulent inflammation into the abdominal cavity, which is a life-threatening surgical complication of the patient.

Placing the TPG in the recipient's body in an inverted position with the positioning of the head of the pancreas downward (in the caudal direction) and the dorsal surface anteriorly provides the convenience of forming vascular anastomoses. At the same time, this position of the PTG provides a passive outflow of pancreatic juice and its passage through the gastrointestinal tract, which makes it possible to prevent the development of post-transplant pancreatitis.

Extraperitoneal placement of TPG in the iliac region allows, in the event of the development of destructive pancreatitis of the graft or failure of the sutures of the duodenal anastomosis, to isolate the abdominal organs from purulent inflammation, to prevent the spread of purulent inflammation into the abdominal cavity. This minimizes the risks of re-surgery, such as transplantation, by eliminating the need to enter the abdominal cavity.

Installation of drainage tubes above and below the RV provides adequate drainage of the surgical site, allows you to control the nature and volume of exudation, and thus preserve the graft in case of necrotic changes.

The inventive method for pancreas transplantation is illustrated in figures 1-5.

Figure 1. View of the preparatory stage of the operation with the removal of a portion of the small intestine from the peritoneal cavity.

Figure 2. Placement of TPG in the right iliac region. Type of venous reconstruction.

Figure 3. View of arterial reconstruction.

Figure 4. View of intestinal reconstruction.

Figure 5. Drainage of the surgical site. The final form of the operation.

Position designations used in the figures:

1 - peritoneum;

2 - a section of the small intestine, excluded from digestion according to Roux;

3 - interintestinal anastomosis;

4 - additional incision of the peritoneum for the small intestine;

5 - the free end of the small intestine;

6 - sutures for fixing the free end of the small intestine to the peritoneum;

7 - sutured incision of the peritoneum;

8 - wing of the ilium and iliac fossa;

9 - pancreas transplant;

10 - portal vein of the pancreas graft;

11 - the recipient's right iliac vein;

12 - Y-shaped vascular insert;

13 - the recipient's right common iliac artery;

14 - interintestinal anastomosis between the donor's duodenum and the free end of the recipient's small intestine;

15 - donor's duodenum;

16 - drainage tubes.

A detailed description of the method and an example of its clinical implementation.

After receiving a pancreas transplant (PTG), pre-transplantation preparation is performed, including: suturing of the donor's duodenum (DPCD) on both sides, arterial reconstruction of the splenic and superior mesenteric arteries using a donor Y-shaped vascular insert.

The recipient has an entrance to the retroperitoneal space on the right by extraperitoneal access according to Gibson: from the symphysis laterally and upwards parallel to the inguinal ligament (https://en.wikipedia.org/wiki/Modified_Gibson_Incision), gaining access to the iliac vessels. After visualization and mobilization of the peritoneum (Fig. 1, pos. 1), it is dissected with a 6 cm incision, thereby gaining access to the intestine. A loop of the small intestine is removed from the abdominal cavity into the wound. According to the Ru method, a 20 cm long section of the small intestine is excluded from digestion (Fig. 1, pos. 2), the continuity of the gastrointestinal tract is restored by forming a small intestinal anastomosis of the "end-to-side" type (Fig. 1, pos. 3), the free end of the small intestine is sutured.

An additional incision is made in the peritoneum with a size corresponding to the transverse size of the small intestine (Fig. 1, pos. 4), through it, the small intestine turned off from digestion is brought out into the wound so that its free end (Fig. 1, pos. 5) recedes from the peritoneum by 4 cm. The free end of the small intestine in the area of the peritoneal incision is fixed with single interrupted sutures (Fig. 1, pos. 6). The dissected peritoneum is sutured tightly (Fig. 1, pos. 7).

In the right iliac fossa along the wing of the ilium (Fig. 2, pos. 8) in an inverted position (head downward, dorsal surface anteriorly), place the TPG (Fig. 2, pos. 9). Further, according to the generally accepted technique, a venous anastomosis is formed between the portal vein of the graft (Fig. 2, pos. 10) and the recipient's right iliac vein (Fig. 2, pos. 11). Then, an arterial fistula is formed between the Y-shaped vascular insert (Fig. 3, pos. 12) and the recipient's right common iliac artery (Fig. 3, pos. 13).

At the next stage of the operation, an interintestinal fistula is formed in a side-to-side manner (Fig. 4, pos. 14) between the DPKD (Fig. 4, pos. 15) and the free end of the recipient's small intestine (Fig. 4, pos. 5 ).

At the final stage, the surgical intervention area is drained with two drainage silicone tubes (Fig. 5, item 16), installed above and below the TPG, the wound is sutured in layers.

According to the claimed method, 7 people with insulin-dependent diabetes mellitus were operated on. Evaluation of the effectiveness of the applied method in the postoperative period was carried out on the basis of data from clinical and instrumental examination. Our studies have shown the effectiveness of the proposed method of pancreatic transplantation with extraperitoneal placement of PTG.

In the group of patients in whom the claimed method of pancreas transplantation was tested, there were no postoperative complications or deaths. In the early stages after pancreas transplantation, patients were completely independent of endogenous insulin with reference blood glucose levels. After rehabilitation measures, the patients achieved recovery and were discharged from the 18th to the 24th day.

The efficiency of the proposed method is confirmed by the given clinical example.

Patient B-va, 34 years old, after a full outpatient examination on July 17, 2018 was admitted with a diagnosis of type 1 diabetes mellitus, complicated course, diabetic nephropathy, diabetic retinopathy. Anamnesis: has been suffering from type 1 diabetes mellitus for more than 20 years with constant insulin replacement therapy. Indicators of glucose levels are not less than 12 mmol / l.

On July 17, 2018, according to the claimed method, the patient underwent pancreas transplantation obtained from a postmortem AB0-compatible anthropometrically suitable donor. The postoperative period was uneventful. Compensation of carbohydrate metabolism with glucose levels of 5.8-5.6 mmol / L was achieved from the third day after the operation with a complete refusal to use exogenous insulin by the time of discharge from the hospital, which took place on the 18th day after transplantation. At the time of discharge, the patient's condition was satisfactory, there were no complaints. In laboratory tests, compensation of basic biochemical parameters.

Duration of observation of the patient for more than 2.5 years - the function of the graft is preserved. Against the background of the diet, there is no need to take exogenous insulin.

Thus, this clinical example shows the high efficiency of the proposed method of pancreas transplantation.

The advantage of this technique is the possibility of delimiting the pathological process in the event of the development of complications of an inflammatory-purulent nature and the prevention of its spread into the abdominal cavity.

The method of pancreas transplantation developed by us allows to increase the duration of the functioning of the PTG and thereby increase the survival rate of patients with insulin-dependent diabetes mellitus, as well as reduce the number of insulin injections or completely refuse to take it.

The inventive method of pancreas transplantation makes it possible to safely remove the pancreas with minimal trauma in case of its dysfunction or necrotic changes.

The invention is practically feasible, is an affordable and highly effective method of radical treatment of patients with insulin-dependent diabetes mellitus.

The method of pancreas transplantation has been tested in the clinic and can be recommended for use in specialized hospitals.

Claims (1)

A method of pancreas transplantation, including pre-transplant preparation of the donor pancreas and duodenum graft, the formation of a vascular anastomosis between the portal vein of the graft and the recipient's vein, characterized in that pre-transplant preparation of the pancreatic graft from both sides of the duodenal artery and reconstruction of the duodenal artery the superior mesenteric artery using a donor Y-shaped vascular insert, after which the recipient has an extraperitoneal access from the symphysis laterally and upwards parallel to the inguinal ligament on the right, the peritoneum is opened with a 6 cm incision; turn off from digestion a section of the small intestine 20 cm long according to Roux, restore the continuity of the gastrointestinal tract by forming a small-intestinal anastomosis of the "end-to-side" type, the free end of the small intestine is sutured; an additional incision of the peritoneum is made with a size corresponding to the transverse size of the small intestine, through it, the small intestine turned off from digestion is brought out into the wound so that its free end recedes from the peritoneum by 4 cm, the intestine in the area of the peritoneal incision is fixed with single interrupted sutures, the dissected peritoneum is sutured tightly ; a pancreas graft is placed in the right iliac fossa along the wing of the ilium in an inverted position with the head downward, with the dorsal surface anteriorly; form a venous anastomosis between the portal vein of the pancreatic graft and the recipient's right iliac vein; form an arterial anastomosis between the Y-shaped vascular insert and the recipient's right common iliac artery; between the prepared donor's duodenum and the free end of the recipient's small intestine, a side-to-side interintestinal fistula is formed; the operation area is drained with two silicone drainage tubes installed above and below the pancreatic graft; the wound is sutured in layers.

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