UA50890U - Method for one-stage surgical correction of pancreatic and biliary duct hypertension in patients with chronic pancreatitis - Google Patents

Abstract

A method for one-stage surgical correction of pancreatic and biliary duct hypertension in the patients with chronic pancreatitis comprises laparotomy, the longitudinal total dissection of the major pancreatic duct involving its ostium, and transverse dissection of the left anterior-lateral duodenal wall. The posterior wall of the choledoch is dissected starting from the orifice of the major duodenal papilla followed by applying the interrupted sutures, first between the upper edges of the dissected choledoch with the duodenal wall; then the choledoch wall is sutured along its perimeter with the tightened pancreatic parenchyma. The inferior edge of the dissected choledoch is sutured with the adjoining wall of the dissected ostium of Wirsung's duct followed by retrocolic longitudinal Roux pancreatojejunoduodenoanastomosis.

Description

improvement of the method of surgical treatment of the pain syndrome, to preserve the exo- and endo-complicated chronic fibro-crine functions of the pancreas, to restore degenerative pancreatitis by introducing the physiological direction of the flow of bile and the pancreatic stage of dissection of the posterior wall of the end (intrapancreatic) juice, to increase the effectiveness of treatment, paracreatic) part of the common bile duct, the recovery of patients, to reduce the number of complications starting from the opening of the large duodenum in the form of dysfunction of the gastrointestinal papilla, in the direction of 3 o'clock of the conventional dial tract, to improve the quality of life. latu 1.5-2 cm long, which provides normal- The method is carried out as follows. The outflow of bile to the duodenum is performed through a physio-upper median laparotomy, dissected in the schluological direction. umbilical cord, duodenum

The task is solved by the fact that in Kocher's bilization, the anterior method is visualized, which includes performing a laparotomy, pos- the surface of the pancreas. By palpation or long total dissection of the main duct with the help of intraoperative ultrasound of the pancreas with its mouth and transverse scanning, the main pancreatic section of the left anterolateral wall of the duodenum is located, which is dissected longitudinally, starting with the small intestine, the new thing is that in the direction of the 3 go- from the tail part of the gland, retreating 2-2.5 cm, the lines of the conditional dial are dissected 1.5-2 cm from its end zone. Next, dissection of the pancreas, the posterior wall of the choledochus (the end of the intrapancreatic current passes through the body and head; the dissection is a zone of tubular stenosis), starting from the thickness of the head of the stomach, from the opening of the large duodenal papilla, from the epigastric gland the anterior arterial ice-stitching with nodal sutures first pancreatoduodenal arcade. A choledochal cystectomy is performed on the upper edge of the dissected choledochal wall. A button probe or choledocheal tube of the duodenum, further along the perimeter, a Fogarty catheter is passed through the stump of the cystic wall of the dissected choledochus is sutured from the sphincter of the duct into the choledochus and further through its terminal intra-pancreatic parenchyma, and the lower edge of the pancreatic area and large duodenal dissection of the choledochus is sutured with the adjacent wall of the papillae - into the duodenum. The left anterolateral wall of the duodenal creatojejunoduodenoanastomosis according to Ru dominates above the protrusion of the dissected mouth of the Versung duct with the following end of the probe or catheter, transversely dissecting the transcolonic longitudinal formation. intestines A final total autopsy is performed

The cause-and-effect relationship between the totality of the main pancreatic duct, including its presenting signs, and the technical result of the mouth. The dissection of the posterior wall of the large duct consists of the following: duodenal papilla and intrapancreatic di- - Longitudinal total dissection of the main duct of the choledochus ( the zone of tubular stenosis) in the nacreatic duct completely eliminates the pancreatic straight line of the 3-hour conditional dial with a length of ductal hypertension and a lymphogenic microcircu- 1.5-2 cm, sufficient to eliminate tubular lyator edema of the pancreas, thanks to the narrowing. The upper edge of the dissected back wall why its exocrine and choledochal is preserved and improved with several knotted sutures - endocrine functions, the manifestations of the abdomen with the duodenum and further, according to the perimetnal pain syndrome. ru, with compacted pancreatic parenchyma, are stopped - Dissection of the posterior wall of the terminal (intrapancreatic the lower edge - with the adjacent adjacent wall of the gap (noy) part of the common bile duct, the cleaned mouth of the virsung duct. Suturing, dissecting from the opening of the large duodenal papilla of the choledoch with adjacent organs and tissues in the direction of 3 o'clock of the conventional clock face, is performed for prevention and allows adequate correction of biliary hypertension, structuring in this area. At a distance of 10-15 cm from the because it is after the previous total posterior ligament of Treitz, the jejunum is crossed by a narrow pancreaticoduodenal papillotomy practically transversally, its distal end is sutured, exposed, compressed (tubular stenosis) by a stapling apparatus, peritonized, conducted - the intrapancreatic part of the choledochus, which dissects - it is transcolonic (through the mesentery of the transverse colon it is extended to the required length (1.5-2 cm) for a normal colon) and anastomoses with the totally dissected biliary outflow into the duodenum. the main pancreatic duct and the transverse - The opening of the wall of the choledochus is performed in the opening of the duodenum (the left anterior zone of its narrowed area (tubular stenosis) on the side wall) in the form of a single pancreatojejuno - in contrast to the "classic" papillosphincterotomy, which duodenoanastomosis according to Ru (at a distance 20-25 cm from it is designed to eliminate only papillostenosis. This anastomosis forms a second: jejunojejuno- - Visual control of the proposed dissection anastomosis end to side). Temporary external drainage of the end part of the choledoch in the direction of 3 o'clock according to Pikovsky is performed. conditional dial completely eliminates (for example, the patient M., 50 years old, the medical history includes) the risk of going beyond the duodenum - Mo13549, was admitted to the surgical department of the region or parenchyma of the pancreas. noy clinical hospital on 09/03/2009 with complaints of - Formation of a solid longitudinal pan- pain in the epigastric area, nausea, weight loss due to creatojejunoduodenoanastomosis according to Ru restores 12 kg, general weakness, malaise. He has been suffering from physiological inflow of pancreatic juice for 5 years, when bile in the duodenum first began to be noted. manifestations of pain syndrome in the upper part of the

Thus, the totality of the above-mentioned poses. She was treated on an outpatient basis. The condition of the patient significantly affected will allow to eliminate the abdominal- has worsened over the last few months. In ser-

In 2009, mechanical jaundice was observed. hero Palpately and visually determined expansion

Upon objective examination, the patient's condition is closer to the main pancreatic duct, the diameter of which is of moderate severity. The skin and visible mucous membranes approximately reach 8-10 mm, the puncture is performed, the skin is slightly yellow in color. Pulse - 72 beats for nodular opaque juice Main pancreatic cord, blood pressure - 130/90 mm Hg. Art. Abdomen during palpation of the duct is completely dissected along the tail, there is a slight, significant pain in the projection of the pancreas, head and mouth in the area of the large duodenal opening. papilla with dissection of the left anterolateral wall

Instrumental examination. Ultrasound: choledoch - duodenum. Considering the biliary hypo- 16 mm in diameter. The gallbladder is enlarged, there is a concentration (blood bilirubin - 38.4 μmol/l), there are no enlargements. Pancreas in the area of choledochal resection is up to 15 mm in diameter, the head reaches 56 mm, in its parenchyma there is calcification of the back walls of the large duodenal papilla and you, in the head and body - cysts (20x30 mm, 30x5 Ohm). Goholedoha (intrapancreatic area) in the direction of the pancreatic duct is expanded in places by 3 o'clock of a conventional dial with a length of 2 cm to 8-10 mm, accommodates calculi. Spleen for complete elimination of tubular stenosis. Upper shena twice; kidneys are normal. the edge of the dissected posterior wall of the 4th node

Computed tomography: the head of the pancreas with atraumatic sutures (thread - Prolene 6/0) of the gland - 52 mm, pancreatic duct - 9 mm, sutured with the wall of the duodenum, further along the lumen - small concretions, calcifications of the parenchyma, the wall dissected choledochus is sutured with pancreatic tissue, head and body cysts with compacted pancreatic parenchyma, and the lower one (20x25mm, 20x40mm). The gall bladder is enlarged, the edge of the choledochal dissection is sutured with the dissected choledochal mouth - 15 mm in diameter. pancreatic duct (3 stitches). Drainage of chole-

The diagnosis was made: chronic fibrosedia due to a stump of the vesical duct according to Pickov-degenerative pancreatitis with severe pancreatitis. The jejunum in the initial section, with tic and biliary ductal hypertension, 15 cm from the ligament of Treitz, was transected for lulosis of the main duct of the pancreas with the help of a stapling device. Distal cyst calcinosis of the parenchyma, compression of the duodenum of the cavitary intestine was carried out behind the colon of the jejunum and portal vein, portal hypertension (through the mesentery of the transverse colon) and anas- compression of the intrapancreatic part of the choledochus, tomosed with a total resection of the pancreas, mechanical jaundice, pancreatogenic diabetes, which duct and a transverse opening of the duodenum is formed. intestine (left anterolateral wall) in the form of

General blood analysis: Er - 3.8410!2/l, Hv - longitudinal pancreatojejunoduodenoanasto - 110g/l, leuk. - 8.6-3/l, e - 1965, p/y - 390, n - 290, s/y - rostrum according to Ru (the second anastomosis is formed at od- 7496, m - 695, l - 1495; SHOE - 12mm /g. General condition 20-25 cm from the first in the form of protein - 58.Ag/l, total bilirubin - 38.4μmol/l, jejunojejunoanastomosis end to side).

KU - 4.2 mmol/l, Ma" - 144 mmol/l, blood sugar - the course of the postoperative period was 18.2 mmol/l without complications. The patient was discharged in satisfactory condition

As planned, on September 7, 2009, it was performed 11 days after the operation. surgical intervention: cholecystectomy, total. Examined after 1, 2, 3 months after the operation. longitudinal pancreatovirsunoduodenopapillotomy, no complaints. According to ultrasound, the ductal pancreas-posterior papillocholedochotomy in intrapancreatic tic and biliary hypertension was not noted, there were no signs of inflammation in the area in the direction of 3 o'clock of the conditional dial, the head of the pancreas was the same, the retrocolonic longitudinal pancreatojejunoduodeno- decreased to Zimm, the abdostomy was completely stopped according to Roux, drainage of choledochus according to Pikovsky. variable pain syndrome, body weight increased

Upper median laparotomy. During the revision, the fat was 4 kg. The sugar indicators of the abdominal organs were normalized, and it was found that hypoglycemia was 6.2; 5.4; 4.8; 4.6; 4.9; 5.2 (mmol/l), the bilirubin gland is sharply compacted, significantly increased in nu - 18.1-19.5μmol/l. head area (5x42mm). Spleen enlarged According to the proposed method, 5 patients were operated twice, gall bladder - 110x60xb5mm, choledoch - patients. These patients did not observe any 15mm, strained. The duodenum is a sharp manifestation of gastrointestinal tract dysfunction. With a compressed and narrowed enlarged head of the stomach, 3 patients who were operated on the nearest gland (subcompensated stenosis), and the stomach analogue, 2 patients had signs of intestinal dysfunction for this reason - dilated and hypotonic. ka (he underwent choledochojejunostomy), because

The veins of the large and small cap are dilated, the pressure syndrome is somewhat reduced, but completely healed. The duodenum is mobilized for Kosh- has not yet stopped.

Computer layout A. Krulevskyi Signature Circulation 26 approx.

Ministry of Education and Science of Ukraine

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SE "Ukrainian Institute of Industrial Property", str. Glazunova, 1, Kyiv - 42, 01601