RU2789210C1 - Method for installing drainages in pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery and oncology. The first drainage 7 mm wide is installed in the right abdomen 1 cm below the XII rib. It is carried out under hepaticojejunostomy under the left lobe of the liver and further into the left subdiaphragmatic space. The second drain 10 mm wide with a multiperforated working area 20 cm long is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is passed through the remaining section of the greater omentum under the gastroenteroanastomosis to the pancreaticojejunoanastomosis, where it wraps 360° around the pancreaticojejunoanastomosis. The distal end of the drain is located along the portal vein in the region of the Glisson gate of the liver to the first segment of the liver. The third drain 10 mm is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is passed through the remaining area of the greater omentum, under the gastroenteroanastomosis, to the pancreaticojejunoanastomosis, where it is passed over the latter and is installed parallel to the first drainage under the hepaticojejunoanastomosis.

EFFECT: method allows to reduce the number of clinically significant pancreatic fistulas, episodes of hemorrhagic complications, the total number of postoperative complications and mortality in patients after pancreatoduodenal resection.

1 cl, 5 dwg, 1 tbl

Description

The invention relates to medicine, surgery, oncology. The method allows to improve the direct indicators of the treatment of patients with various diseases of the pancreas, requiring the implementation of pancreatoduodenal resection in various modifications.

An increase in the incidence of pancreatic diseases, including chronic pancreatitis and tumors of the periampullary zone, necessitates the choice of the safest and most effective surgical option with the least number of complications. The basis of surgical treatment of various benign and malignant diseases with lesions of the head of the pancreas is the Kaush-Whipple operation - pancreatoduodenal resection [1]. The most common complications after this operation are the formation of pancreatic and biliary fistula, postoperative gastrostasis of various degrees of severity [2]. The most formidable complication, by right, is the development of pancreatic fistula. In severe cases, it leads to both a worsening of the postoperative period and a significant increase in mortality [3].

The basis for the prevention of severe postoperative complications after pancreatoduodenal resection is drainage of the abdominal cavity [4]. Perhaps, the number, variability and duration of installation of postoperative drains is comparable to the number of options for pancreatoduodenal resection itself, however, today surgeons around the world do not have a consensus on the number, material and method of installing insurance postoperative drains [5].

In the available modern literature, we did not find sources about the features of one or another option for installing insurance intra-abdominal drains during pancreatoduodenal resection, and only in one work by Italian authors it was demonstrated that with a standard installation of drains, their dislocation often occurs with a number of subsequent surgical problems [6 ].

Thus, there is no data on the optimal option for installing drains, which leads to the search for new options for installing drains that allow standardizing the approach to this manipulation and reducing postoperative risks.

The option of installing intra-abdominal insurance drains involves draining all potentially formed fluid accumulations in the sloping zones of the postoperative area after pancreatoduodenal resection. Also of particular importance is the fact that the treatment of marginal pancreatic necrosis that develops in all cases after transection of the pancreas is also facilitated by adequate drainage with the possibility of active washing of intraoperatively installed insurance drains.

The task to be solved by the claimed invention is to expand the possibilities of the surgical method of treatment by creating ways for the safe outflow of pancreatic juice from the area of surgical intervention in the presence of a pancreatic fistula.

The proposed method of installing drains. To improve the results of treatment of patients with various pancreatic tumors, the following standard protocol for the installation of intra-abdominal insurance drains was developed and implemented in the surgical clinic of the Botkin Hospital.

Surgical intervention in the volume of pancreaticoduodenal resection in any modification (with resection of the stomach or preservation of the pylorus) was performed under combined general anesthesia in the operating room. After the completion of the reconstructive stage of the operation, drains were installed according to the following scheme:

- the first drainage 7 mm wide is installed in the right abdomen 1 cm below the XII rib, carried out under the hepaticojejunostomy under the left lobe of the liver and further into the left subdiaphragmatic space;

- the second drainage 10 mm wide with a multiperforated working area 20 cm long is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is passed through the remaining section of the greater omentum under the gastroenteroanastomosis to the pancreaticojejunoanastomosis, where it turns 360 degrees around the pancreaticojejunoanastomosis, distal end drainage is located along the portal vein in the region of the Glisson gate of the liver to the first segment of the liver;

- the third drainage of 10 mm is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is carried out through the remaining section of the greater omentum, under the gastroenteroanastomosis, to the pancreaticojejunoanastomosis, where it is carried out above the latter and is installed parallel to the first drainage under the hepaticojejunoanastomosis.

To confirm the effectiveness of the proposed method of treatment

an analysis of the results of its application is proposed.

Patients with various diseases of the pancreas since 2018 when performing pancreatoduodenal resection. A comparative study was conducted evaluating the use of standard PVC drains in a retrospective group and silicone drains installed by a modified method. The following indicators were evaluated: duration of surgery, volume of blood loss, postoperative complications according to Clavien-Dindo, postoperative complications according to ISGPS, postoperative bed-day.

Thus, the proposed option of installing intra-abdominal insurance drains allows not only to reduce the number of clinically significant pancreatic fistulas (50% versus 8%), as well as episodes of hemorrhagic complications (22% versus 12%), but also significantly reduce the total number of postoperative complications (56/ 50 vs 21/50) and mortality (10% vs 2%) in patients after pancreatoduodenal resection. To demonstrate the presented option for installing insurance intra-abdominal drains, a clinical example is presented.

Clinical example. Patient Ya., 58 years old, was admitted in a planned manner for surgical treatment for ductal adenocarcinoma of the pancreatic head. Performed pancreatogastroduodenal resection with the formation of pancreaticojejuno-, hepaticojejuno-, gastroentero-and interintestinal anastomoses. The installation of insurance intra-abdominal drains was performed according to the method indicated above. The first drainage was installed in the right lateral half of the abdomen, somewhat lower (1-2 cm) than the level of the XII rib. Silicone drainage 7 mm wide with 3/4 slots was placed behind the hepaticojejunostomy, over the hepatoduodenal ligament, under the left lobe of the liver and further into the left subdiaphragmatic space (Fig. 2A). The second drain (silicone, 10 mm, with a multiperforated zone of 20 cm) was installed in the left lateral half of the abdomen, also 2 cm below the XII rib, passed through the greater omentum under the gastroenteroanastomosis to the pancreaticojejunoanastomosis, where it was wrapped 360 degrees around the pancreaticojejunoanastomosis, the distal end of the drain located along the portal vein in the region of the Glisson gate of the liver to the first segment (Fig. 2 B). The third drainage (silicone, 10 mm, with grooves for 3/4 of the length) was installed in the left lateral region of the abdomen 1 cm below the XII rib, slightly above and anterior to the second drainage, also passed through the remaining area of the greater omentum, under the gastroenteroanastomosis, to the pancreaticojejunoanastomosis , where it is held over the last and installed parallel to the first drain under the hepaticojejunostomy (Fig. 2B).

In the postoperative period, the drains were sequentially removed: from the hepaticojejunoanastomosis on the 7th day, from the pancreaticojejunoanastomosis on the 9th and 12th days after normalization of the amylase level in the discharge. The patient was discharged on the 15th day of the postoperative period without complications.

Description of images Fig. 1 - Multispiral computed tomography in patients after pancreatoduodenal resection, three-dimensional reformation. A) Patient 8 days after pylorus-preserving pancreaticoduodenal resection. B) the patient on the 7th day after pylorus-preserving pancreaticoduodenal resection.

Fig. 2 - Multispiral computed tomography in a patient after pancreatogastroduodenal resection, three-dimensional reformation.

A. Green indicates the first drain to the hepaticojejunostomy.

B. The first drainage to the pancreaticojejunoanastomosis is marked in yellow.

B. The second drain to the pancreaticojejunoanastomosis is marked in red.

Bibliography.

1. Gupta, V. B., Bellurkar, A. N., Changole, S. S., Nandagawli, V. R., & Umare, G. (2016). Whipple's procedure: Yesterday and today. International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD), 6(1), 1-5.

2. Jilesen AP, van Eijck CH, in't Hof KH, van Dieren S, Gouma DJ, van Dijkum EJ. Postoperative Complications, in-Hospital Mortality and 5-Year Survival After Surgical Resection for Patients With a Pancreatic Neuroendocrine Tumor: A Systematic Review. World J Surg (2016) 40:729-48. 10.1007/s00268-015-3328-6

3. Pedrazzoli S. Pancreatoduodenectomy (PD) and Postoperative Pancreatic Fistula (POPF): A Systematic Review and Analysis of the POPF-related Mortality Rate in 60,739 Patients Retrieved From the English Literature Published Between 1990 and 2015. Med (Baltimore) (2017) 96:e6858. 10.1097/MD.0000000000006858

4. Fisher W.E. Intraperitoneal Drainage and Pancreatic Resection. Adv Surg (2018) 52:205-22. 10.1016/j.yasu.2018.03.013

5. Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, et al. Surgical Techniques and Postoperative Management to Prevent Postoperative Pancreatic Fistula After Pancreatic Surgery. World J Gastroenterol (2019) 25:3722-37. 10.3748/wjg.v25.i28.3722

6. Marchegiani G, Ramera M, Viviani E, Lombardo F, Cybulski A, Chincarini M, Malleo G, Bassi C, Zamboni GA, Salvia R. Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study. Langenbecks Arch Surg. 2019 Mar;404(2):213-222. doi: 10.1007/s00423-019-01760-7. Epub 2019 Feb 15. PMID: 30771076.

Claims (1)

A method for draining the postoperative zone in patients after pancreaticoduodenal resection, which consists in installing three silicone drains, one of which is 7 mm wide, is installed in the right abdomen 1 cm below the XII rib, is performed under the hepaticojejunoanastomosis under the left lobe of the liver and further into the left subdiaphragmatic space, the second 10 mm wide with a multiperforated zone of 20 cm is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is passed through the remaining section of the greater omentum under the gastroenteroanastomosis to the pancreaticojejunoanastomosis, where it turns 360 ° around the pancreaticojejunoanastomosis, the distal end of the drainage is located along the portal vein in the region of the Glisson's gate of the liver to the first segment of the liver, the third 10 mm wide is installed in the left lateral region of the abdomen 1-2 cm below the XII rib, is carried out through the remaining section of the greater omentum, under the gastroenteroanastomosis, to the pancreaticojejunoanastomosis, where it is carried out over the latter and set parallel to the first drainage under the hepaticojejunostomy.

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