RU2765113C1 - Method for surgical treatment of chronic pancreatitis complicated by intraductal hypertension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. Resection of the pancreatic head is performed using an electrocoagulator, leaving a parenchyma layer along the medial edge of the duodenum, containing branches of the anterior and lower pancreatoduodenal arteries, which provide its blood supply. A segment of the jejunum is isolated on a vascular pedicle at a distance of 30-40 cm from the duodenojejunal junction 15-18 cm long. The proximal end of the segment is sutured, and the distal end, after the formation of a longitudinal pancreatojejunostomy, is anastomosed with the lower-horizontal part of the duodenum with “separate sutures”. The Treyz's ligament is dissected.

EFFECT: method provides an increase in the efficiency of surgical intervention, a decrease in the likelihood of postoperative complications, an improvement in digestion processes due to the creation of a physiological supply of pancreatic secretion and the inclusion of the duodenal phase of digestion, a decrease in the risk of duodenopancreatic reflux, which reduces the risk of complications such as cholangitis, duodenostasis, postoperative pancreatitis, preservation of normal microbial intestines, improving the quality of life of patients in the postoperative period.

1 cl, 1 dwg, 3 ex

Description

The invention relates to medicine and can be used in surgical departments in the treatment of chronic pancreatitis complicated by intraductal hypertension.

Known methods of surgical treatment of chronic pancreatitis, complicated by intraductal hypertension, do not adequately provide the physiological flow of pancreatic secretions into the duodenum and, accordingly, the activation of enzymes, which in turn leads to the development of secondary exocrine insufficiency. Most of them exclude more than 70 cm of the small intestine from digestion, which significantly reduces the absorption area of food nutrients and contributes to the development of bacterial overgrowth syndrome. At the same time, the disadvantages of the known methods that ensure the flow of pancreatic secretions into the duodenum are the absence of a resection stage with excision of the fibrous-altered tissue of the pancreatic head, which with a high degree of probability will lead to recurrence of the pain syndrome, a high risk of reflux into the pancreatic and bile ducts.

A known method of surgical treatment of chronic pancreatitis complicated by pancreatic hypertension, including the creation of an artificial passage in the head of the pancreas in the area of obliteration of the ducts. At the same time, the preserved part of the main pancreatic duct is connected to the lumen of the duodenum. Stenting of the duct and the created passage is performed to maintain permanent drainage (RF Patent No. 2612806, IPC A61F 2/00, publ. 2017). longitudinal pancreatotomy is performed in the area of the body with opening of the main pancreatic duct, duodenotomy in the area of the lateral wall of the middle third of the descending duodenum opposite the major duodenal papilla. Further, a bougie with a removable head and a plastic guide tube is introduced into the head of the pancreas in the area of obliteration of the ductal system through the pancreatotomy opening and advanced in the proximal direction to the site of obliteration of the duct. Then an artificial passage is created in the head of the pancreas, for which the bougie is passed into the lumen of the duodenum through its medial wall, closely adjacent to the head of the pancreas, the removable head is removed and the bougie is removed, a stent is inserted through the guide tube, the guide tube is removed, after which the pancreatotomy opening is sutured.

The disadvantage of this method is:

1. The absence of a resection stage of the operation, including the removal of fibrous tissue of the pancreatic head, as one of the main causes of pain in chronic pancreatitis.

2. Danger of possible malignancy while maintaining fibrous tissue of the pancreatic head

3. High risk of reflux into the area of pancreatojejunostomy, due to the destruction of the closing function of the OBD and higher duodenal pressure.

4. The need for periodic replacement of the stent, with a high probability of its obturation (stones) or compression by fibrous tissue.

A known method of surgical treatment of chronic pancreatitis complicated by intraductal hypertension (V.M. Kopchak et al., Principles of direct operations on the pancreas in the surgical treatment of chronic pancreatitis, Bulletin of Surgery 2012, Vol. 171, No. 3, pp. 30-31), consisting in the allocation of a segment of the small intestine on the feeding vascular pedicle, longitudinal pancreaticoduodenotomy, starting from the tail of the pancreas and ending with its mouth. In this case, duodenotomy is performed at the level of the middle third of the descending part of the duodenum in the projection of the major duodenal papilla, then pancreatojejunoduodenoanastomosis "side-to-side" is formed.

The disadvantages of this method of surgical treatment of chronic pancreatitis are:

1. The absence of a resection stage of the operation, including the removal of a fibrously altered head, as a "pacemaker" of pathological changes in the pancreas, which may be the cause of non-stopping pain syndrome caused by non-drainable ducts of the head of the I and II order, including the uncinate process.

2. Danger of possible malignancy while maintaining the head.

3. High risk of reflux into the area of pancreatojejunostomy and the bile duct, due to the destruction of the closing function of the OBD. Reflux is promoted by high duodenal pressure at the level of its vertical part, where the duodenum is included in the anastomosis with an isolated segment of the jejunum.

The closest is the method of surgical treatment of chronic pancreatitis complicated by intraductal hypertension (Frey CF, Mayer KL Comparison of Local Resection of the Head of the Pancreas Combined with Longitudinal Pancreaticojejunostomy (Frey Procedure) and Duodenum-Preserving Resection of the Pancreatic Head (Beger Procedure). World J Surg 2003; 27: 1217-1230), including laparotomy, mobilization of the duodenum according to Kocher, resection of the head of the pancreas using an electrocoagulator, leaving a layer of parenchyma along the medial edge of the duodenum containing branches of the anterior and lower pancreatoduodenal arteries that provide its blood supply, extraction of the jejunum according to Roux, longitudinal pancreatojejunostomy throughout the tail, body, and wound cavity of the head of the pancreas, suturing the postoperative wound.

The disadvantages of this method is the exclusion from digestion of the jejunum 70-80 cm long, which creates favorable conditions for colonization of its colonic microflora and infection of the pancreatic secretion, with a high risk of progression of the bacterial overgrowth syndrome. In addition, a significant reduction in the length of the intestinal tube reduces the area of absorption of food nutrients. The method does not provide the physiological flow of pancreatic secretion into the duodenum and, accordingly, the activation of enzymes, which leads to the progression of exocrine insufficiency.

The objective of the invention is to eliminate these shortcomings, increase the effectiveness of surgical intervention, reduce the likelihood of postoperative complications, improve digestion by creating a physiological intake of pancreatic secretion and the inclusion of the duodenal phase of digestion, reducing the risk of duodenopancreatic reflux, maintaining a normal intestinal microbiome, improving the quality of life of patients in the postoperative period.

To solve the problem in the method of surgical treatment of chronic pancreatitis complicated by intraductal hypertension, including laparotomy, mobilization of the duodenum according to Kocher, resection of the pancreatic head using an electrocoagulator, leaving a layer of parenchyma along the medial edge of the duodenum, containing branches of the anterior and lower pancreatoduodenal arteries, providing its blood supply, longitudinal pancreatojejunostomy along the tail, body, and wound cavity of the head of the pancreas, suturing the postoperative wound, it was proposed to isolate a segment of the jejunum on a vascular pedicle, at a distance of 30-40 cm from the duodenojejunal junction, 15-18 cm long. the jejunum is sutured, and the distal end, after the formation of a longitudinal pancreatojejunoanastomosis, is anastomosed with the lower horizontal part of the duodenum "end to side" with single-row separate sutures, after which the ligament is dissected Treitz.

EFFECT: method allows to ensure the physiological flow of pancreatic secretion into the duodenum as a result of the formation of pancreatojejunoduodenoanastomosis on an isolated segment of the jejunum, which leads to the activation of enzymes and improves digestion. The formation of an isolated segment of the jejunum increases the area of absorption of food nutrients. Dissection of the ligament of Treitz and the formation of jejunoduodenoanastomosis at the level of the lower horizontal part of the duodenum is the prevention of duodenopancreatic reflux, which reduces the risk of complications such as cholangitis, duodenostasis, and postoperative pancreatitis.

The drawing shows a diagram of resection of the pancreatic head with a longitudinal dissection of the main pancreatic duct and the formation of pancreatojejunoduodenoanastomosis.

The designation adopted in the figure: 1 - duodenum, 2 - resected cavity of the head of the pancreas, 3 - main pancreatic duct, 4 - isolated segment of the jejunum on a vascular pedicle, 5 - pancreatojejunoanastomosis, 6 - jejunoduodenoanastomosis, 7 - lower horizontal part of the duodenum, 8 - duodenojejunal transition. The method is carried out as follows.

Mobilization of the duodenum 1 according to Kocher is performed, then resection of the head of the pancreas 2 with excision of fibrous tissue, then the main pancreatic duct 3 is dissected longitudinally to the tail. This is sufficient to ensure adequate decompression of the ductal system, in the absence of strictures in the caudal gland. Then, at a distance of 30-40 cm from the duodenojejunal junction, it is at this level that the jejunum becomes more mobile and convenient for performing pancreatojejunoduodenoanastomosis without tension, an isolated segment of the small intestine 4 is isolated on a vascular pedicle 15-18 cm long, the proximal end of the segment is sutured, and the distal remains open.

This length of the segment of the jejunum is the most convenient for the formation of pancreatojejunoduodenoanastomosis, with a length of less than 15 cm, tension of the jejunum occurs in the area of the duodenojejunoanastomosis, and with a length of more than 18 cm, technical difficulties appear in the formation of duodenojejunoanastomosis, deformation of the excess segment of the jejunum with narrowing of its lumen and violation entry of pancreatic secretions into the duodenum.

An isolated segment of the jejunum is carried out behind the colon and a pancreatojejunoanastomosis 5 is formed, including the wound cavity of the head 2, with an atraumatic thread 3.0 with a single-row continuous suture. After completion of this stage of the operation, end-to-side jejunoduodenoanastomosis is formed with the distal stump of the jejunal segment with 6 single-row separate sutures with atraumatic thread 3.0, which completes the pancreatojejunoduodenal fistula.

Formation of jejunoduodenoanastomosis by anastomosis of the distal end of the jejunal segment with the lower horizontal part of the duodenum, i.e. is performed at the level of the lower horizontal part 7 of the duodenum, since there is the lowest intraluminal pressure, and, accordingly, the risk of duodenopancreatic reflux is lower.

A revision of the duodenojejunal junction 8 is carried out, the angle of which is leveled (dissection of the ligament - Strong's operation), since it can cause a delay in the evacuation of the duodenal chyme into the jejunum, and, as a result, the development of duodenal hypertension with the likelihood of reflux of the contents into the area of pancreatojejunoanastomosis.

Example 1

Patient Sh., 44 years old, suffering from chronic pancreatitis complicated by intraductal hypertension and bacterial overgrowth syndrome for 10 years. Complains of pain in the epigastrium with errors in the diet, periodically loose stools. On examination: Breath test - 50 ppm, Fecal elastase-1 - 90 mcg/g. During the illness notes a decrease in body weight by 10 kg. The diagnosis was confirmed clinically, laboratory tests, abdominal ultrasound and contrast-enhanced CT.

In September 2020, an operation was performed using the proposed method. At the same time, pancreatojejunoduodenoanastomosis was formed on an isolated segment of the jejunum 15 cm long, isolated at a distance of 40 cm from the duodenojejunal junction. At the same time, the distal segment of the jejunum was anastomosed with the lower horizontal part of the duodenum "end-to-side" with single-row separate sutures. After that, the ligament of Treitz was cut. Drains were installed in the subhepatic space and omental bag. The surgical wound was sutured in layers.

Postoperative period without complications. Discharged on the 12th day after the operation. He was examined on an outpatient basis in December 2020. He has no complaints, he is on a diet. Attention was drawn to the improvement of exocrine pancreatic function (Fecal elastase-1 - 200 mcg/g) and the absence of signs of bacterial overgrowth syndrome (Breath test 5 ppm). The patient also noted the normalization of the stool, the absence of dyspeptic symptoms, pain syndrome and an increase in body weight by 3 kg.

Example 2

Patient K., 40 years old, suffering from chronic pancreatitis complicated by intraductal hypertension for 8 years, has been abusing alcohol for about 15 years. Complains of loose stools, pain in the epigastric region after eating fatty foods. During the examination: Breath test - 70 ppm, Fecal elastase-1 - 70 mcg/g. During the course of the disease, there is a decrease in body weight by 5 kg. The diagnosis is confirmed clinically, laboratory tests, abdominal ultrasound and CT with contrast.

The operation was performed according to the above method. Pancreatojejunoduodenoanastomosis was formed on an isolated segment of the jejunum 18 cm long, isolated at a distance of 35 cm from the duodenojejunal junction. Postoperative period without complications.

During control examinations, the indicators of laboratory and instrumental data were within the normal range, according to fluoroscopy of the stomach and duodenum 12, there were no violations of the passage of food through the gastrointestinal tract. The patient was discharged in a satisfactory condition on the 15th day after the operation.

When examined after 3 months, there is an improvement in the exocrine function of the pancreas (Fecal elastase-1 - 180 μg / g), no signs of bacterial overgrowth syndrome (Breath test - 6 ppm). The patient has gained weight, there are no dyspeptic and endocrine disorders, there is no pain syndrome, and the ability to work has been restored.

Example 3

Patient D., aged 37, suffering from chronic pancreatitis complicated by intraductal hypertension and bacterial overgrowth syndrome for 8 years. Complains of epigastric pain, loose stools. On examination: Breath test - 88 ppm, Fecal elastase-1 - 60 mcg/g. During the illness notes a decrease in body weight by 6 kg. The diagnosis was confirmed clinically, laboratory tests, abdominal ultrasound and contrast-enhanced CT.

An operation was performed according to the proposed method: laparotomy, subtotal duodenum-preserving resection of the pancreatic head with a longitudinal dissection of the main pancreatic duct and the formation of pancreatojejunoduodenoanastomosis on an isolated segment of the jejunum 16 cm long, isolated at a distance of 30 cm from the duodenojejunal junction. Revisions of the duodenojejunal junction and dissection of the ligament of Treitz. Postoperative period without complications.

Discharged on the 13th day after the operation. Examined on an outpatient basis. Complaints does not show, keeps to a diet. Attention was drawn to the improvement of exocrine pancreatic function (Fecal elastase-1 - 210 µg/g) and the absence of signs of bacterial overgrowth syndrome (Breath test 6 ppm). The patient also noted the normalization of the stool, the absence of dyspeptic symptoms, pain syndrome and an increase in body weight by 2 kg.

According to the developed method, 14 patients suffering from chronic pancreatitis complicated by intraductal hypertension were operated on. The age of the patients ranged from 34 to 50 years. Of these, the vast majority of men were noted - 13 patients and one woman. A comprehensive examination of patients before surgery and in the long-term after surgical treatment included, in addition to a physical examination, a standard set of laboratory and instrumental research methods, a mandatory study of fecal elastase-1 in order to assess the exocrine function of the pancreas and a hydrogen breath test to identify the syndrome of excessive bacterial growth.

In the postoperative period, the effectiveness of the operation method was evaluated on the basis of EGDS data with an examination of the pancreatojejunoduodenoanastomosis zone, abdominal ultrasound, abdominal CT, fluoroscopy of the stomach and duodenum, as well as fecal elastase-1 and hydrogen breath test.

The course of the postoperative period in all patients was smooth. All patients achieved full recovery in a short time, with improvement in the studied parameters (fecal elastase-1 and hydrogen breath test). There was no hospital mortality.

The application of the proposed method allows to increase the efficiency of surgical intervention in this category of patients. Postoperative complications are extremely rare, if the recommendations are not followed by the patient. The quality of life of patients in the postoperative period is significantly improved.

Claims (1)

A method for the surgical treatment of chronic pancreatitis complicated by intraductal hypertension, including laparotomy, mobilization of the duodenum according to Kocher, resection of the pancreatic head using an electrocoagulator, leaving a layer of parenchyma along the medial edge of the duodenum containing branches of the anterior and lower pancreatoduodenal arteries that provide its blood supply, longitudinal pancreatojejunostomy along the tail, body and wound cavity of the pancreatic head, suturing the postoperative wound, characterized in that a segment of the jejunum is isolated on a vascular pedicle at a distance of 30-40 cm from the duodenojejunal junction 15-18 cm long, the proximal end of which is sutured, and the distal end , after the formation of a longitudinal pancreatojejunoanastomosis, anastomose with the lower horizontal part of the duodenum "end to side" with single-row separate sutures, after which the ligament of Treitz is dissected.

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