RU2803012C1 - Method of forming pancreatogastroanastomiosis after pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine; abdominal surgery; oncology.

SUBSTANCE: stomach and the proximal part of the pancreatic stump are mobilized. In the region of the lower third of the body of the posterior wall of the stomach, a transverse gastrotomy is performed. The first row is formed with interrupted sutures, while the needle is punctured from the inside of the stomach wall through all layers 0.3–0.5 cm from the edge of the gastrotomy opening, and the needle is punctured at the main pancreatic duct. Then invagination of the mobilized area of the pancreatic stump is performed. On the back wall of the stomach in the region of lesser curvature, distal to the first row of sutures along the central axis, departing from the line of the first row of sutures, a needle is injected with the capture of the serous-muscular wall with a puncture through 0.5–0.6 cm. The second injection of this suture is performed on the greater curvature of the stomach symmetrically with the first one with the capture of the serous-muscular wall of the stomach, while the formed suture in the form of a triangle is taken on a holder. Similarly, with the capture of the greater and lesser curvature, two or three more sutures are formed, which are alternately tied, starting from the distal one. The first suture of the second row is tied last, with the immersion of the proximal edge of the gland and the first row of anastomosis into the formed tunnel from the posterior wall of the stomach.

EFFECT: method increases the effectiveness of treatment due to the formation of a "tunnel" from the posterior wall of the stomach, minimizing the risk of suture eruption, as well as the absence of the need to make an incision on the anterior wall of the stomach.

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Description

The invention relates to medicine, namely to abdominal surgery and oncology. It is part of the reconstructive stage after performing pylorus-preserving pancreaticoduodenectomy.

This surgical intervention is accompanied by a high (up to 48%) number of complications. One of the most controversial and discussed questions is which part of the digestive tract (small intestine or stomach) should be used, and whether isolated suturing of the duct is required when forming an anastomosis (Patyutko Yu.I., 2013). The search for ways to incorporate the pancreatic stump into the digestive tract continues and various anastomotic options are proposed: intussusception pancreatojejunostomy with antireflux properties; pancreatojejunostomy on drainage (external, lost); longitudinal pancreaticojejunostomy; end-loop (telescopic) pancreaticojejunostomy; pancreatogastroanastomosis and others. (Kuchin D.M., 2017). Among the advantages of pancreatogastroanastomosis, the gastric wall that is more convenient and better supplied with blood for performing anastomosis compared to the small intestine and the possibility of simple decompression of the anastomotic area with a gastric tube are most often indicated. The most common disadvantage is the need to avoid enteral nutrition in patients with pancreatic fistula. The proposed methods for forming pancreatogastroanastomosis by foreign authors (Bassi S. et all 2006; Bartsch D. 2012) have a number of disadvantages. The most common are the need to perform an anterior gastrostomy (double trauma to the stomach wall), a large number of sutures on the pancreatic tissue, which, given its “soft” consistency, increases the risk of anastomotic failure, and the technical difficulty of reproducing the author’s technique. Thus, it is necessary to create a simple and reliable method of pancreaticogastroanastomosis, applicable in patients with a “soft” pancreas and a narrow pancreatic duct.

The closest analogue: the method of forming pancreatogastroanastomosis during pancreatoduodenal resection, described in the work of Bartsch D. et all in 2012. The distal edge of the gland is mobilized 2-3 cm from the splenic vein and surrounding tissues. A drain is placed in the pancreatic duct and secured with a 5-0 polyfilament absorbable suture. Then the posterior wall of the stomach is incised for 2 cm. A 2-0 purse-string suture is placed through the anterior wall with an absorbable monofilament thread. The gland is passed into the lumen of the stomach for 2 cm. Mattress sutures are passed through the posterior wall of the stomach and the pancreatic tissue. Then the purse string suture is tightened. The anterior gastrostomy opening is sutured.

This method has a number of disadvantages, the main ones being:

- the need to perform a gastrotomy on the anterior wall of the stomach, thus causing double trauma to the stomach

- the main point of fixation is one purse-string suture, which, if cut through, can cause complete failure of the anastomosis.

The basis of the invention is the task of creating a method for forming pancreatogastroanastomosis after pancreaticoduodenectomy, providing higher efficiency of treatment due to the formation of a “tunnel” from the posterior wall of the stomach, minimizing the danger of cutting sutures, and also eliminating the need to make an incision on the anterior wall of the stomach.

The solution to this problem is ensured by the fact that in the method of forming pancreatogastroanastomosis after pancreatoduodenal resection, including lymph node dissection and removal of the organ complex consisting of the duodenum, the head of the pancreas with the uncinate process, the distal part of the common bile duct, the gallbladder and the initial part of the jejunum, the stomach is mobilized along the lesser curvature to the left gastric, along the greater curvature - to the left gastroepiploic vessels, while if it is necessary to increase the perimeter of the intussusception area, skeletonization of the lesser curvature of the posterior wall of the stomach is performed, then the proximal part of the pancreatic stump is mobilized by 3.0

- 4.0 cm distal from the intersection; in the area of the lower third of the body of the posterior wall of the stomach, at an equidistant distance from the greater and lesser curvatures, a transverse gastrotomy is performed, with the length of the incision coinciding with the diameter of the stump of the proximal edge of the pancreas; a stent is installed in the main pancreatic duct, which is fixed with a 5-0 absorbable polyfilament thread, the first row is formed with interrupted sutures with a 4-0 non-absorbable polyfilament thread, while the needle is inserted from the inside of the stomach wall through all layers 0.3-0.5 cm from the edge gastrotomy opening, and the needle is punctured close to the main pancreatic duct; a knot is tied to the wall of the stomach, and the distance between the seams is 0.5-0.6 cm; then invagination of the mobilized area of the pancreatic stump is performed; then on the posterior wall of the stomach in the area of the lesser curvature, distal to the first row of sutures along the central axis, departing from the line of the first row of sutures by 2-2.5 cm, a needle is inserted, capturing the seromuscular wall with a puncture after 0.5-0.6 cm, and the second injection of this suture is performed on the greater curvature of the stomach symmetrically with the first, also capturing the seromuscular wall of the stomach, while the formed suture in the form of a triangle is taken onto a holder; in the same way, at a distance of 1-1.5 cm, depending on the thickness of the parenchyma of the gland and the wall of the stomach, two or three more sutures are formed, capturing the greater and lesser curvatures, which are tied alternately, starting from the distal one, while the first suture of the second row is tied in last, with the immersion of the proximal edge of the gland and the first row of the anastomosis into the formed tunnel from the posterior wall of the stomach.

The invention is illustrated in Fig. 1, which shows the mobilized distal part of the pancreas with the posterior wall of the stomach brought to it; fig. 2, which shows the formed first row of anastomosis (a pancreatic stent is installed in the main pancreatic duct); fig. 3, which shows alternately applied gray-serous sutures on the posterior wall of the stomach; fig. 4, which shows the final view of the double-row anastomosis with the posterior wall of the stomach.

The essence of the invention is: the proximal part of the pancreatic stump is mobilized 3.0 - 4.0 cm distal from the intersection site (Fig. 1). In the area of the lower third of the body of the posterior wall of the stomach, at an equidistant distance from the greater and lesser curvatures, a transverse gastrotomy is performed. The length of the incision coincides with the diameter of the stump of the proximal edge of the pancreas. A stent is placed in the main pancreatic duct and secured with a 5-0 absorbable polyfilament suture. The first row is formed with interrupted sutures using 4-0 non-absorbable polyfilament suture. The needle is inserted from the inside of the stomach wall through all layers 0.3-0.5 cm from the edge of the gastrotomy opening. The needle is inserted in close proximity to the main pancreatic duct. The knot is always tied to the wall of the stomach. The distance between the seams is 0.5-0.6 cm. According to the described method, the first row of the anastomosis is formed (Fig. 2). Next, invagination of the mobilized area of the pancreatic stump is performed. A needle is inserted into the posterior wall of the stomach in the area of the lesser curvature, distal to the first row of sutures along the central axis, 2-2.5 cm away from the line of the first row of sutures, capturing the seromuscular wall with a puncture after 0.5-0.6 cm. Second The injection of this suture is made on the greater curvature of the stomach symmetrically with the first one, also capturing the seromuscular wall of the stomach. The formed seam in the form of a “triangle” is not tied, but is taken onto a holder. Similarly, at a distance of 1-1.5 cm, depending on the thickness of the parenchyma of the gland and the wall of the stomach, two or three more sutures are formed (Fig. 3), which are alternately tied starting from the distal one, capturing the greater and lesser curvatures (Fig. 3). The first suture of the second row is tied last, with the proximal edge of the gland and the first row of the anastomosis immersed in the formed “tunnel” from the posterior wall of the stomach (Fig. 4).

The method was tested on 6 patients for one year in a surgical department. All patients had a combination of a narrow main pancreatic duct and a “soft” pancreas. Good results were obtained. One patient developed pancreatic fistula gr. B, the cause of which was pancreatitis of the gland stump. Repeated surgery was not required. There were no complications such as failure of pancreaticogastroanastomosis.

Example No. 1 Patient A. 68 years old

Diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) C25.0 Malignant neoplasm of the head of the pancreas. Pancreatic head cancer cT3N0Mo, condition after external percutaneous transhepatic cholangiodrainage.

Concomitant: Hypertension stage II Risk 3. CHF I, NYHA FC I. Diabetes mellitus type 2, compensated. Obesity 2 degrees. COPD

The operation was performed: Pylorus-preserving pancreaticoduodenectomy.

Under endotracheal anesthesia, after processing the surgical field in the navel area, a trocar was inserted into the abdominal cavity, and carboxyperitoneum was applied. During the audit: there is no effusion in the abdominal cavity, there is no carcinomatosis in the abdominal cavity; gallbladder with a thickened wall. An upper midline laparotomy was performed. In the projection of the head of the pancreas, a space-occupying formation of dense consistency measuring up to 4 cm in diameter is determined; in the area of the hepatoduodenal ligament, lymph nodes enlarged to 1 cm are detected. Lymphodissection of the hepatoduodenal ligament was performed with the isolation of the portal vein and hepatic arteries; the common hepatic artery has a typical structure. Cholecystectomy “from the bottom”, common bile duct with a diameter of 1 cm, with a thickened wall, is crossed above the confluence of the cystic duct. A. gastro-duodenale is isolated at the base, clipped, and crossed. The mobilization of the duodenum according to Kocher was carried out. The greater omentum is mobilized. The omental bursa was opened through the gastrocolic ligament. A vascular arch is left along the greater curvature of the stomach. The stomach is mobilized to the left gastroepiploic artery. The pancreas is processed along the upper and lower edges, the space between the gland and v. is tunneled. portae; In the area of the isthmus, an infiltrative process is determined; no signs of tumor invasion into the vein are detected. The pancreatic duct is visualized, up to 2 mm in diameter. The consistency of the parenchyma of the gland is soft and easily vulnerable. A section of the pancreas and common bile duct was sent for urgent histological examination - no tumor cells were detected. Using an endostapler, the duodenum was crossed 2 cm below the pylorus; the jejunum was also cut off with an endostapler at a distance of 20 cm from the ligament of Treitz and brought into the upper floor of the abdominal cavity. The organ complex was gradually separated from the portal vein with ligation of its tributaries, the uncinate process was mobilized with lymph node dissection along the right semicircle of the superior mesenteric artery, invasion into a. mesenterica superior is not noted. Reconstructive stage: taking into account the unpronounced pancreatic duct and the soft consistency of the pancreas stump, a decision was made to perform submersible pancreaticogastroanastomosis using the original technique. In the projection of the gland stump on the posterior wall of the stomach, a gastrotomy opening 3.5 cm long was made in the transverse direction. A stent was installed into the lumen of the main pancreatic duct and fixed with a 5-0 Vicryl thread. Using interrupted Prolene 3-0 sutures, the pancreas and stomach wall were sutured along the entire circumference to form the first row of anastomosis. Then, 3 seromuscular sutures were placed alternately on the posterior wall of the stomach using Vicryl 3-0 thread on both sides of the first row. The sutures are tied alternately, the gland is immersed 3 cm into the “tunnel” from the back wall of the stomach.

The first loop from the ligament of Treitz of the small intestine was mobilized, the place for the choledocho-enteroanastomosis was marked, a continuous choledocho-enteroanastomosis was applied with a 4-0 prolene suture in the anterior colon, 40 cm distally, a gastroenteroanastomosis was applied with a two-row continuous suture with insertion of a feeding tube.

A PVC drainage was installed on the right - in the subhepatic space under the hepatoduodenal ligament, on the left to the area of pancreaticogastroanastomosis, the end of the drainage was brought to the area of the omental bursa. Hemostasis control - dry. Napkin counting is everything. Layer-by-layer suturing of wounds. Aseptic dressing.

Operation time: from 09:30 to 13:00

Macropreparation: Organocomplex (head of the pancreas, common bile duct, gallbladder, fiber of the greater and lesser omentum with l/u).

There were no complications in the immediate or late postoperative period. The patient was discharged on the 13th day.

Information sources

1. Patyutko, Yu.I. Various types of pancreatodigestive anastomoses during pancreaticoduodenectomy / Yu.I. Patyutko, N.E. Kudashkin, A.G. Kotelnikov // Ann. Hir. Hepatol. - 2013. - T18, No. 3 - P. 9-15.

2. Bassi S.The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. Mar 2017; 161(3):584-591.doi: 10.1016/j.surg.2016.11.014. Epub 2016 Dec 28.

3. Bartsch DK, Langer P, Kanngieβer V, Fendrich V, Dietzel K. A simple and safe anastomosis for pancreatogastrostomy using one binding purse-string and two transfixing mattress sutures. Int J Surg Oncol. 2012;2012:718637. doi:10.1155/2012/718637

4. Kuchin Denis Mikhailovich. Choosing the optimal method for forming a pancreatodigestive anastomosis during gastropancreatoduodenal resection: dissertation of a candidate of medical sciences: 01/14/17 / Kuchin Denis Mikhailovich 2017. - 101 p. https://fips.ru/registers-doc-view/DeEndhttps://fips.ru/registers-doc-view/ClStart

Claims (2)

1. A method for forming pancreatogastroanastomosis after pancreaticoduodenal resection, including lymph node dissection and removal of the organ complex consisting of the duodenum, the head of the pancreas with the uncinate process, the distal part of the common bile duct, the gallbladder and the initial part of the jejunum, characterized in that the stomach is mobilized along the lesser curvature to the left gastric, along the greater curvature - to the left gastroepiploic vessels, then the proximal part of the pancreatic stump is mobilized 3.0-4.0 cm distal from the intersection site; in the area of the lower third of the body of the posterior wall of the stomach, at an equidistant distance from the greater and lesser curvatures, a transverse gastrotomy is performed, with the length of the incision coinciding with the diameter of the stump of the proximal edge of the pancreas; a stent is installed in the main pancreatic duct, which is fixed with a 5-0 absorbable polyfilament thread, the first row is formed with interrupted sutures with a 4-0 non-absorbable polyfilament thread, while the needle is inserted from the inside of the stomach wall through all layers 0.3-0.5 cm from the edge gastrotomy opening, and the needle is punctured at the main pancreatic duct; a knot is tied to the wall of the stomach, and the distance between the seams is 0.5-0.6 cm; then invagination of the mobilized area of the pancreatic stump is performed; then on the posterior wall of the stomach in the area of the lesser curvature, distal to the first row of sutures along the central axis, departing from the line of the first row of sutures by 2-2.5 cm, a needle is inserted, capturing the seromuscular wall with a puncture through 0.5-0, 6 cm, and the second injection of this suture is performed on the greater curvature of the stomach symmetrically with the first, also capturing the seromuscular wall of the stomach, while the formed suture in the form of a triangle is taken onto a holder; in the same way, at a distance of 1-1.5 cm, depending on the thickness of the parenchyma of the gland and the wall of the stomach, two or three more sutures are formed, capturing the greater and lesser curvatures, which are tied alternately, starting from the distal one, while the first suture of the second row is tied in last, with the immersion of the proximal edge of the gland and the first row of the anastomosis into the formed tunnel from the posterior wall of the stomach. 2. The method according to claim 1, characterized in that if it is necessary to increase the perimeter of the intussusception area, skeletonization of the lesser curvature of the posterior wall of the stomach is performed.