RU2792254C1 - Method for draining cysts of the head of the pancreas - Google Patents

Abstract

FIELD: pancreatobiliary surgery.

SUBSTANCE: in the preoperative period, the size of the pancreas, as well as the size and localization of the cyst are determined. Based on the results of the data obtained, a frame stent is made from a perforated PVC tube with two holes at the end. After duodenotomy, a stylet with a frame stent put on it is inserted into the cyst cavity by twisting movements in the direction of the pancreatic cyst, forming an internal fistula between the cyst cavity and the duodenal lumen. The stent is positioned with its end with holes protruding into the lumen of the duodenum by 1.5 cm, then the stylet is removed.

EFFECT: effective localization of cysts communicating with the Wirsung duct and not communicating with it, minimal trauma; reduction of operation time due to simplicity, reduction of the frequency of intraoperative and postoperative complications.

1 cl, 3 dwg, 2 ex

Description

The invention relates to medicine, namely to surgical pancreatology in the treatment of complications of both acute and chronic pancreatitis. In connection with the increase in the incidence of acute pancreatitis, the increase in the number of its chronic forms, the number of complications of this disease also increases, among which one of the first places is occupied by pancreatic cysts. The search for the least traumatic and functionally more beneficial methods of treating this complication is relevant to this day.

The level of technology.

In connection with the increase in the number of patients with acute pancreatitis, various complications of acute pancreatitis and later chronic ones also increase. The most common complication is the development of postnecrotic cysts of the pancreas, which in some cases require active surgical tactics and surgical correction (Reis A.B. Surgical treatment of patients with postnecrotic cysts of the pancreas / A.B. Reis, S.V. Morozov., V. L. Poluektov., V. T. Dolgikh // Medicine in Kuzbass. - 2015, - V. 14, No. 2. - P. 48-52.). Depending on the localization, cysts of the head, body and tail of the pancreas are isolated. Being in close relationship with the duodenum, the pancreatic part of the common bile duct, nerve plexuses, cysts of the head and body of the pancreas manifest themselves most actively. Among the clinical manifestations, chronic pain syndrome, dyspeptic disorders, disorders of exocrine function, and, as a result, weight loss, deterioration in the quality of life can be distinguished.

Approaches to the surgical treatment of pancreatic cysts are fundamentally different from each other (Andren - Sandberg A., Dervenis C. / Pancreatic pseudocysts in the 21st century. Part I: classification, pathophysiology, anatomic considerations and treatment. JOP. 2004. No. 5. p 8-24.).

The most radical and at the same time the most traumatic are techniques based on resection of the pancreatic head with a cyst, cystectomy. These include pancreatoduodenal resection, Frey's operation (S.F. Bagnenko, A.A. Kurygin "Chronic pancreatitis", 2000). The disadvantages of these techniques include the high technical complexity of their implementation, a high percentage of postoperative complications up to death. In addition, the physiological process of digestion is disturbed, malabsorption syndrome develops, which leads to unsatisfactory functional results of this operation.

Methods of internal drainage of pancreatic cysts are widely used (Tarasenko S.V., Rakhmaev T.S., Kopeikin A.A. Method for internal drainage of pancreatic pseudocysts. RF patent No. 2319463, IPC A61B 17/11, publ. date 20.03. 2008.). The essence of these techniques is the imposition of the anastomosis of the cyst with the stomach, duodenum or jejunum. There are options for imposing an anastomosis with a cyst on a turned off loop according to Roux, or on a loop with an inter-intestinal anastomosis according to Brown. Their main advantage is their physiology. Pancreatic juice is involved in digestion, operations are less traumatic compared to resection options, technically simpler. However, they have their own complications, namely, due to the reflux of gastric and intestinal contents, chronic inflammation develops in the fistula area, which further leads to scarring of the anastomoses with the development of manifestations of chronic pancreatitis, pain syndrome, recurrence of cysts. Complications such as failure of cystojejuno- or gastrojejunoanastomoses associated with improper operation technique and aggression of pancreatic juice are also not uncommon. The disadvantages include the need to impose an additional inter-intestinal anastomosis.

With the development and wide promotion of minimally invasive and endoscopic techniques in surgery, methods of minimally invasive external and internal drainage of pancreatic cysts appeared (Ivshin V.G. Original methods of percutaneous invasive interventions on the abdominal organs / V.G. Ivshin. - Tula: Aquarius, 2016. - 146 p.) incl. using ultrasound devices (ultrasound) (Sablin I.V. Method for endoscopic drainage of pancreatic cysts. Patent of the Russian Federation No. 2190967, IPC A61B 17/00, publ. date 10.20.2001) Ultrasound or gastroscope. At the same time, drainage is introduced into the cyst cavity through a puncture in the anterior abdominal wall, through which the cyst is emptied, intraductal hypertension is stopped. The undoubted positive aspect is the short duration of these operations. There is no need for these patients to be in the intensive care unit, the postoperative bed-day is reduced. The disadvantages of these techniques include the following: high risk of damage to internal organs and blood vessels, bleeding into the cyst cavity, bleeding into the free abdominal cavity. Being a foreign object associated with the external environment, drainage has a risk of infection. In addition, when the cavity of the cyst communicates with the ductal system of the pancreas, an external pancreatic fistula is formed, which subsequently will not close on its own.

It is well known that internal drainage of a cyst is the most physiological and most preferred method for eliminating ductal hypertension (Sparrow A.V. Is there a future for drainage operations in chronic pancreatitis? A systematic critical review of the literature / A.V. Vororbey., A.Ch. Shuleiko. , E. I. Vizhinis, Y. N. Orlovsky // Annals of Surgical Hepatology. - 2016, - V.21, No. 14. - P. 70-83.). When performing internal drainage, the participation of pancreatic juice in digestion is preserved, the pain syndrome is steadfastly stopped, a number of complications are prevented, such as the formation of external pancreatic fistulas, irritation of the skin in the anastomosis area.

A known method of imposing cystoduodenoanastomosis (Sedov A.P. et al. The method of imposing cystoduodenoanastomosis. Patent of the Russian Federation No. 2332178, IPC A61B 17/11, date publ. 08.27.2008) involves duodenotomy followed by anastomosis between the lumen of the duodenum and pseudocyst. In this case, the cyst is pre-punctured with a trocar from the lumen of the duodenum. Remove the trocar stylet. Four provisional sutures are placed on opposite sides of the circumference of the trocar sleeve. Then duodenorrhaphy is performed.

The method of formation of cystoduodenoanastomosis (Babaev A.A. The method of formation of cystoduodenoanastomosis. Patent of the Russian Federation No. 2318459, IPC A61B 17/11, published date 10.03.2008, Bull. No. 7.) includes duodenotomy. Puncture of a pancreatic cyst. From the puncture site, the cyst is opened with a V-shaped incision. The segments of the cut are 3 cm. The segments are located at an angle of 60 ° to each other. The cyst is opened through the medial wall of the duodenum below the major duodenal papilla. Stitches are applied to capture the wall of the duodenum and the fibrous capsule of the cyst. The duodenotomy opening is sutured.

There is also a method of duodenocystovirsungostomy (Martov Yu.B., Podolinsky S.G., Shchastny A.T. Method of duodenocystovirsungostomy. Patent of Belarus No. 4887, IPC A61B 17/00, publ. date 12/30/2002). The essence of the method consists in excising a section of the duodenum (2x2 cm) with an adjacent section of the duodenal wall with stitching the edges with interrupted sutures, opening the lumen of the Wirsung duct into the cyst cavity, introducing drainage into the pancreatic duct and bringing it out through the stomach and esophagus

The above methods, in our opinion, have common drawbacks, namely: the need for suturing the cyst capsule and pancreatic tissue. It is known that the cyst capsule is not always well expressed and it is necessary to suture the pancreatic tissue, which, against the background of chronic inflammation, does not have sufficient strength, this leads to eruption of the sutures, maintenance of chronic inflammation, and, as a result, scarring of the anastomosis. The need to perform a V-shaped incision, suturing the medial wall of the duodenum creates a high risk of damage to the blood vessels of the duodenum and the head of the pancreas, tissue ischemia, damage to the ductal system of the pancreas, intrapancreatic part of the common bile duct. These techniques are not applicable in the absence of adherence of the cyst wall to the medial wall of the pancreas and the weak expression of the cyst capsule.

The prototype of the claimed method is the work of A.V. Pugaeva with co-authors, who developed a method for the treatment of chronic false cysts of the pancreatic head communicating with the main pancreatic duct (Pugaev A.V., Achkasov E.E. Method for the treatment of chronic false cysts of the pancreatic head communicating with the main pancreatic duct. Patent of the Russian Federation No. 2277870, IPC А61В 17/11, date of publication 06/20/2006). With this method, an upper median laparotomy is performed. Next, cystostomy is performed on the free area of the cyst. Then, during the revision of the cyst cavity, the mouth of the confluence of the Wirsung duct into it is revealed. Then, after a transverse duodenotomy, the adjoining walls of the duodenum and cysts are perforated without excision. During interposition of the pancreatic tissue, the cyst wall is perforated towards the upper horizontal part of the duodenum, while a tunnel is formed under the pancreatic capsule, represented by connective tissue, followed by perforation of the wall of the upper horizontal part of the duodenum. Further, a plastic perforated drainage with a diameter of 5 mm is carried out from the lumen of the duodenum into the cyst cavity through the formed tunnel. Further, drainage from the side of the cyst through the Wirsung duct flowing into it is carried out transpancreatically through the parenchyma to the anterior surface of the pancreas. The pancreatic part of the drainage is brought out through a puncture in the anterior abdominal wall in the left hypochondrium. The second end of the drainage from the lumen of the duodenum is passed into the stomach and removed through the anterior wall of the stomach in the form of a gastrostomy through an additional puncture in the left hypochondrium. In the postoperative period, after 4 weeks, the through drainage is removed, replacing it with a single-lumen capillary with a diameter of 2 mm. The capillary is removed after another 2 weeks.

The disadvantages of this method include opening the lumen of the cyst in the abdominal cavity, the need for a gastrostomy, which can lead to infection and the development of purulent complications, prolonged closure of these fistulas. This technique is not feasible when the cysts are located on the posterior surface of the head and body of the pancreas. In the presence of chronic capitate pancreatitis or fibrosing pancreatitis, tunneling is not possible due to the lack of layer differentiation. The quality of life of patients also decreases due to the need to walk with external drains for 6 weeks.

The purpose of the invention.

The objective of the invention is to create a universal method for internal drainage of cysts of the pancreatic head with minimal trauma of surgical intervention, providing the excretory function of the gland directly into the lumen of the duodenum.

Disclosure of the invention.

The proposed method consists in the fact that the cyst is drained with simultaneous installation of a frame stent in the created fistula from the duodenal lumen into the cyst cavity with the creation of a long and adequate drainage of the cyst contents into the duodenal lumen. At the same time, it is possible to individually select a perforated frame stent in diameter and length, depending on the size of the pancreas, the size and localization of the cyst itself, taking into account the single-complexity of the cyst. The duration of the stent is also individual, depending on the timing of the reduction of the cyst, clinical manifestations. There is no need for a gastrostomy or external drainage.

The novelty of the proposed method is the formation of cystoduodenoanastomosis by internal drainage of a cyst in the head of the pancreas by introducing a frame perforated stent made of polyvinyl chloride tube, delivered from the lumen of the duodenum into the cavity of the cyst with a stylet with a stent put on it. The stent is selected individually for each patient, taking into account the size, location, multi-chamber cyst.

This method is carried out as follows. In the preoperative period, an ultrasound examination of the pancreaticoduodenal zone, multislice computed tomography (MSCT) with contrast enhancement is performed to clarify the size of the pancreatic cyst, the presence of septa, the relationship to the wall of the duodenum, superior mesenteric and pancreaticoduodenal vessels, localization of the cyst. Operative access - upper midline laparotomy. Next, an intraoperative revision is carried out. According to the results of the preoperative and intraoperative examination (depending on the size of the pancreas, the size of the cyst, the depth of the cyst), a frame perforated stent of the required diameter and length is made from a PVC tube (1, Fig. 1). It is taken into account that the stent should protrude 1.5 cm into the lumen of the duodenum and have 2 holes in this area. This is necessary to prevent blockage of the stent by food masses and to remove the stent in the future. Also, the specified length of the part of the stent protruding into the lumen of the duodenum prevents unwanted migration of the stent into the lumen of the small intestine. The stent is put on a stylet (2, fig. 1), the edge of which is conically narrowed, but not pointed. If necessary, an intraoperative ultrasound examination (ultrasound) is performed. A transverse duodenotomy is performed in the descending section (3, Fig. 1). Visualized large duodenal papilla (4, Fig 1). According to the shortest and safest trajectory, in the direction of the pancreatic cyst (5, Fig. 1), the stylet with a frame stent put on it is inserted into the cyst cavity by twisting movements. If necessary, the stylet is removed to check for drainage. Isolation of the contents of the cyst or pancreatic juice through the drainage indicates the correct setting of the drainage. If necessary, for control, intraoperative ultrasound is performed. The stylet is removed. A 1.5 cm stent with 2 holes protrudes into the lumen of the duodenum (6, Fig. 1) (7, Fig. 1). Hemming of the frame drainage to the duodenum is not required. The "blunt" expansion of the pancreatic tissues prevents injury to the latter, as well as blood vessels and capillaries, and the frame stent performs an additional hemostatic function. The duodenotomy opening and the abdominal cavity are sutured tightly.

The significant differences of this method are as follows:

- minimal invasiveness, puncture of the cyst with a stylet with a rounded end is used, which pushes the tissues apart, and does not cut through them, reducing the invasiveness of the intervention;

- the introduction of the stent is carried out from the lumen of the duodenum, which excludes the entry of the contents of the cyst into the free abdominal cavity in the postoperative period.

- the stent is selected individually for each patient. The size, localization, multi-chamber cysts are taken into account.

- there is no need to open the lumen of the cyst, which eliminates the development of complications in the postoperative period (bleeding, the development of purulent-septic complications).

- effective guaranteed functioning of the created cystoduodenoanastomosis;

- there is no need to excise, cut, stitch the walls of the duodenum and pancreas;

- no additional external drainage is carried out;

- this method is versatile and applicable for cysts both predominantly with an anterior and predominantly posterior location, with single-chamber and multi-chamber cysts, with cysts communicating with the Wirsung duct and not communicating with it, in the presence of pancreatic tissue interposition.

Technical result

The developed method for the treatment of cysts of the pancreatic head provides effective physiological internal drainage of the cyst for a given period, determined by the individualized tasks of postoperative treatment of chronic pancreatitis, and has minimal trauma. The method allows to reduce the time of hospitalization. With its versatility, it is applicable for various individual variants of the anatomical structure of the pancreas and the location of the cysts of the pancreatic head, and allows to reduce the frequency of intraoperative and postoperative complications.

Clinical examples.

Example 1. Patient A. 47 years old. Hospitalized in the surgical department on 10/13/2019. Diagnosis at admission: chronic pancreatitis. relapsing course. Cyst of the head of the pancreas. From the anamnesis: in 2014 he underwent a median laparotomy for mixed pancreatic necrosis. In the future, 2-3 times a year hospitalization for relapses of acute pancreatitis. In 2017, according to ultrasound data, a cyst was detected in the region of the head of the pancreas, 3 × 3 cm in size. Subsequently, an increase in the size of the cyst was noted. On admission: general condition of moderate severity. Body temperature is normal. Reduced nutrition. The tongue is wet. The abdomen is not swollen. The anterior abdominal wall is soft, there is a postoperative scar along the midline. On palpation, pain in the epigastric region, right hypochondrium. According to the ultrasound examination, the pancreas is diffusely heterogeneous, coarse-grained. Head thickness 58 mm, body 30 mm, tail 34 mm. Wirsung's duct is unevenly expanded up to 5-7 mm. In the projection of the head, along the posterior surface, there is a cystic formation 48×42 mm, with a wall up to 3 mm. According to MSCT data, in the region of the head of the pancreas, there is a volumetric formation of liquid density, with clear, even contours, 49 × 44 mm in size, located in the pancreatic tissue along the posterior surface. After conservative therapy, relief of pain, the patient underwent surgery: upper median laparotomy, revision, duodenotomy, internal drainage of the cyst on a framed perforated drainage according to the method described above. According to MSCT data, the drainage diameter was 4.7 mm (14 phr.) and 5 cm long. There were no complications in the postoperative period. Discharged in a satisfactory condition on the 10th day. Came back for a follow-up visit 6 months later. On examination, the patient's condition was satisfactory, he had no complaints. Gained 3 kg in weight. The abdominal wall is soft and painless on examination. According to ultrasound education in the head of the pancreas 20×18 mm with internal drainage. Wirsung's duct is not dilated. According to esophagogastroscopy, there was no drainage migration, the end of the drainage was visualized from which pancreatic juice was released in portions.

Example 2. Patient A., 30 years old, was hospitalized in the clinic on February 7, 2020 with a diagnosis of chronic pancreatitis. relapsing course. Cyst of the head of the pancreas. Upon admission, he complained of girdle pain in the upper abdomen with irradiation to the back, weight loss, poor appetite. In history for 2 years, episodes of exacerbation of recurrent pancreatitis. Chronic pain syndrome. During this time, 9 times was treated permanently. He developed a fear of eating, progressively lost weight. Resigned from work due to frequent sick leave. Objective examination: general condition of moderate severity. Body temperature is normal. Reduced nutrition. Tongue wet, furred. The abdomen is not swollen. The anterior abdominal wall is soft, painful in the epigastric region, a dense, painful infiltrate is palpated there. On ultrasound examination, the pancreas is diffusely heterogeneous, coarse-grained. The Wirsung duct was dilated to 7 mm. In the projection of the head, an anechoic formation is 51×46 mm, with a wall of up to 7 mm not adjacent to the medial wall of the duodenum. According to MSCT, in the region of the head of the pancreas, there is a volumetric formation of liquid density, with clear, even contours, 54×40 mm in size, located on the posterior surface of the gland.

Taking into account the localization of the cyst on the posterior surface of the pancreatic head, a long history of the disease, the patient underwent internal drainage of the cyst by applying a cystoduodenostomy on a frame perforated drainage according to the method described above. Based on MSCT data, a drainage diameter of 4.7 mm (14 phr.) and a length of 6 cm was chosen. There were no complications in the postoperative period. Discharged in a satisfactory condition on the 8th day. On examination after 6 months, he had no complaints. According to ultrasound, the cyst in the region of the head of the pancreas (5, Fig. 2) is 21×20 mm with internal drainage (1, Fig. 2). Wirsung's duct is not dilated. At the control examination after 1 year, the condition is satisfactory. Didn't make any complaints. Gained 8 kg in weight. Got a job. According to ultrasound, the formation in the head of the pancreas is 21×18 mm. Esophagogastroduodenoscopy (EGDS) in the lumen of the duodenum (8, Fig. 3) visualized the end of the drainage with two holes (1, Fig. 3) from which pancreatic juice flows in portions. The drain has been removed. There were no complications.

Bibliography

1) Bagnenko S.F. Chronic pancreatitis: A guide for doctors / A.A. Kurygin, N.V. Rukhlyada, A.D. Smirnov. - St. Petersburg: Peter, 2000. - 420 p.

2) Babaev A.A. The method of formation of cystoduodenoanastomosis. RF patent No. 2318459, IPC A61 B 17/11, date of publication. 03/10/2008, Bull. No. 7.

3) Sparrow A.V. Is there a future for drainage operations in chronic pancreatitis? Systematic critical literature review / A.V. Vororbey., A.Ch. Shuleiko., E.I. Vizhinis, Yu.N. Orlovsky // Annals of surgical hepatology. - 2016. - V. 21, No. 14. - S. 70-83.

4) Zubritsky V.F. Open prosthetic virsungoplasty - a new type of surgical intervention in the surgical treatment of chronic pancreatitis / V.F. Zubritsky, N.M. Zvolskaya // Medical Bulletin of the Ministry of Internal Affairs. 2017. - No. 1 (86). - S. 7-9.

5) Ivshin V.G. Original methods of percutaneous invasive interventions on the abdominal organs / V.G. Ivshin. - Tula: Aquarius, 2016. - 146 p.

6) Martov Yu.B., Podolinsky S.G., Shchastny A.T. The method of duodenocystovirsungostomy. Belarus patent No. 4887, IPC А61В 17/00, date of publication. 12/30/2002.

7) Nartailakov M.A. Surgical treatment of chronic pancreatitis and pancreatic cysts / M.A. Nartailakov., N.V. Peshkov., N.A. Murmansky., I.Z. Salimgareev., I.I. Galimov // Kazan medical journal. - 2007, - T. 88, No. 5. - S. 472-476.

8) Pugaev A.V., Achkasov E.E. A method for the treatment of chronic false cysts of the pancreatic head communicating with the main pancreatic duct. RF patent No. 2277870, IPC А61В 17/11, date of publication. 06/20/2006.

9) Flight A.B. Surgical treatment of patients with postnecrotic pancreatic cysts / A.B. Flight, St. Morozov., V.L. Poluektov., V.T. Dolgikh // Medicine in Kuzbass. - 2015, - Vol. 14, No. 2. - From 48-52.

10) Sablin I.V. Method for endoscopic drainage of pancreatic cysts. RF patent No. 2190967, IPC А61В 17/00, date of publication. October 20, 2001.

11) Sedov A.P. et al. The method of imposing cystoduodenoanastomosis. RF patent No. 2332178, IPC А61В 17/11, date of publication. 08/27/2008.

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13) Tarasenko S.V., Rakhmaev T.S., Kopeikin A.A. Method for internal drainage of pancreatic pseudocysts. RF patent No. 2319463, IPC А61В 17/11, date of publication. 03/20/2008.

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Claims (1)

A method for draining cysts of the pancreatic head, including laparotomy and duodenotomy, internal drainage of the cyst, characterized in that the size of the pancreas, the size and localization of the cyst are determined in the preoperative period, then, based on the results of the data obtained, a frame stent is made from a perforated PVC tube with two holes for end; after duodenotomy is performed, with twisting movements in the direction of the pancreatic cyst, a stylet with a frame stent put on it is inserted into the cyst cavity, forming an internal fistula between the cyst cavity and the lumen of the duodenum, while the stent is positioned in such a way that its end with holes protrudes into the lumen of the duodenum 1.5 cm, after which the stylet is removed.

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