UA68018A - Method for surgical treatment of patients with cancer of head of pancreas complicated with duodenal stenosis - Google Patents

Abstract

The method for the surgical treatment of patients with cancer of the head of pancreas complicated with the duodenal stenosis comprises the decompression transcutaneous transhepatic cholangiohepaticostomy. The cholangiohepaticostoma is transformed into the extracorporeal allogenic biliodigestive by-pass. With this end in view, Brown's interloop gastrojejunoanastomosis in applied. The jejunal loop is disconnected by aboral anastomosis according to Roux technique and fixed to the parietal peritoneum. Then the draining tube is inserted through the stub wound in the abdominal wall and connected with the cholangiohepaticostomal drainage with the aim of generating the extracorporeal biliodigestive by-pass draining the bile into the intestine.

Description

Description of the invention

The invention relates to the field of medicine, namely to abdominal surgery, and can be used for 2 surgical treatment of pancreatic head cancer complicated by duodenal stenosis.

A known method of surgical treatment of cancer of the head of the pancreas by performing a radical operation is pancreatoduodenal resection (1), when the distal half of the stomach, the head of the pancreas with the duodenum and the distal branches of the bile duct are removed.

However, when using this method in patients with prolonged jaundice, there is a high risk of developing acute liver failure with a probable fatal outcome, as well as low resectability of tumors of this location.

There is also a known method of eliminating jaundice and reducing the degree of risk by performing decompressive percutaneous, transhepatic cholangiostomy (21.

But when performing this method, there is a significant loss of bile, the danger of endogenous infection of the bile ducts, hygienic, aesthetic, social problems that worsen the patient's quality of life. 12 The closest to the proposed technical solution is the method of surgical treatment of jaundice by forming a biliodigestive anastomosis between the gallbladder or hepatocholedochus and the organs of the gastrointestinal tract (stomach, duodenum, or jejunum), which provides an internal biliodigestive passage of bile and saves the patient from an external biliary fistula.

The disadvantage of this method is the impossibility of its use in the absence of conditions for the formation of biliodigestive anastomosis in those cases when: a) the gall bladder has been removed or cicatrically shrunk; b) thin and thin-walled hepaticocholedoch unsuitable for anastomosis; c) tumor infiltration prevents use for anastomosis of the stomach or duodenum; d) the structure of the vessels of the mesentery limits the mobility of the jejunum and does not allow it to be brought to the gallbladder 29 or hepaticocholedochus, "

The invention is based on the task of improving the method of surgical treatment of head cancer patients by transforming an external percutaneous transhepatic biliary fistula into an extracorporeal biliodigestive shunt in the absence of conditions for the formation of a traditional intra-abdominal biliodigestive anastomosis. co

This will ensure the flow of bile into the intestines, which will save the patient from an external biliary fistula.

The task is solved by the fact that, according to the invention, the cholangiohepaticostomy is transformed into an extracorporeal allogeneic biliodigestive shunt, for which a gastrojejunoanastomosis is performed with an interloop anastomosis according to Brown, a loop of the jejunum aboral to the anastomosis, is excluded according to Ru, it is fixed to 3o of the parietal abdomen, through a puncture wound in the abdominal wall, a tubular drain and ee are introduced into the excluded loop, connect it with a cholangiohepaticostomy drain to create an extracorporeal biliodigestive shunt, draining bile into the intestines.

Figure 1 shows the external drainage of bile through a percutaneous transhepatic cholangiohepaticostomy. "

Fig. 2 shows an extracorporeal biliodigestive shunt, formed by connecting C 0 cholangiohepaticostomy drainage with a drain inserted into the loop of the jejunum excluded by Ru, which is located more aborally than the gastrojejunal anastomosis and interloop confluence according to Brown, where:

From" a) cholangiohepaticostoma; b) gastrojejunoanaetomosis; c) interloop confluence according to Brown; d) Roux anastomosis; b e) turning off the loop of the jejunum according to Ru;

Ge | g) tubular drainage immersed behind Witzel in the closed loop of the jejunum; g) extracorporeal allogeneic biliodigestive shunt. o The method is carried out as follows. A laparotomy is performed. Having made sure that the tumor grows into the duodenum and causes its stenosis | (Fig. 1), form an anteroperitoneum anterior gastrojejunoanatemosis with an interloop confluence according to Brown. If the conditions exclude the possibility of an intra-abdominal biliodigestive anastomosis, the loop of the jejunum is crossed at lOsm in the amoral direction from the interloop junction according to Brown and an anastomosis is formed according to Roux, which excludes the loop of the jejunum with a length of 20 cm. The oral end of the excluded loop is sewn tightly and fixed to the 29th parietal peritoneum. Into the abdominal cavity through a puncture of the abdominal wall 5 cm from the cholangiostomy is injected into. a polyvinyl chloride tube, which is immersed according to Witzel into the closed loop of the jejunum. The drains are connected, thus forming an extracorporeal allogeneic biliodigestive shunt, which ensures the flow of bile to the intestines and relieves the patient of a superficial biliary fistula.

Example of a specific implementation 60 Patient K., 56 years old, who underwent a cholecystectomy in the past, came to the surgical department

Odesa Central Military Clinical Hospital POK 27.08.02 with a two-year history of oncology (medical history Mo13508). In July 2000 jaundice of mechanical genesis appeared for the first time, caused by a tumor of the large duodenal papilla. Endoscopic papillectomy led to restoration of bile outflow and elimination of jaundice. Histological examination of the drug made it possible to verify cancer of the large or duodenal papilla. The patient was offered radical surgery, which he refused. He received 2 courses of polychemotherapy with mitocin and 5-fluorouracil. In July 2001 there was a recurrence of jaundice. It was possible to ensure the outflow of bile by stenting. Another relapse of jaundice occurred in June 2002. in connection with stent encrustation. Attempts to remove the old stent and replace it with a new one were unsuccessful.

It was possible to provide decompression by percutaneous transhepatic cholangiostomy, and antegrade tubular drainage was carried out in the hepaticochoyaedoh. Jaundice resolved again.

2 months after the formation of cholangiohepaticostoma, in August 2002. upon admission to the hospital, the main complaints were profuse vomiting, weight loss of 20 kg, weakness. Bile losses reached 100 Oml/day. There was no jaundice. The results of X-ray and endoscopic examination indicated /o uncompensated stenosis of the duodenum.

Laparotomy made it possible to clarify that the cause of the stenosis is a large stationary tumor of the head of the pancreas, which compresses the vertical knee of the duodenum. The tumor is unresectable. Tubular drainage can be felt throughout the sclerosed wall of the common bile duct, which had a diameter of 100 mm (Fig. 1). An anteropelvic anterior gastrojejunal anastomosis with an interloop junction according to Braun 7/5 (Welfler's operation) was formed. The formation of an intra-abdominal biliodigestive joint is impossible: the gallbladder is absent, the duodenum is infiltrated by a tumor, the architecture of the vessels of the mesentery does not allow the jejunum to approach the sclerosed and unsuitable for anastomosis to the common bile duct without tension. The outflow of bile to the intestines was ensured by converting a percutaneous transhepatic cholangiostomy into an extracorporeal biliodigestive shunt. To do this, the jejunum was cut 10 cm more aborally than the Brown's joint. An end-to-side anastomosis closed a loop of the jejunum with a length of 2000 cm (Fig. 2). The closed loop was sewn to the parietal peritoneum and a drainage tube was inserted into it according to Witzel, which was brought out through a puncture wound in the abdominal wall 5 cm from the cholangiohepaticostomy.

By connecting the hepaticocholangiostomy drain with a tube inserted into the closed jejunal loop, an extracorporeal halogen biliodigestive shunt was created, ensuring the flow of bile into the jejunum. The postoperative period was uneventful. He was discharged with a restored gastrointestinal passage, a functioning extracorporeal biliodigestive shunt. During 6 months, there were no signs of jaundice or cholangitis, the patient's quality of life improved significantly.

The proposed method implements a new approach to the treatment of pancreatic head cancer complicated by hepatic (mechanical) jaundice. In comparison with the prototype, the proposed method allows patients with cancer of the head of the pancreas, complicated by tumoral stenosis of the duodenum, to ensure the outflow of bile to the intestines not by an intra-abdominal biliodigestive anastomosis, but by an extracorporeal allogeneic biliodigestive (su shunt, which is created between the cholangiostomy and the loop of the jejunum , excluded according to Roux aborally gastrojejunal anastomosis and interloop joint according to Brown.

Literature: "about 1. Pancreatic surgery / A.A. Shalymov, S.A. Shalymov, M.E. Nechitaylo,

A.P. Radzihovsky.-Simferopol: Tavrida, 1997. - 553p. 2. Balalkin A.S. Endoscopic abdominal surgery.-M.: IMA-press, 1996. - 1526.

Z. Geshelyn S.A. Urgent cancer surgery. - Kyiv: Zdorovye, 1988. - 1976. « 4. Guide to medicine / Ed. R. Berlow, - M.: Mir, 1997. - Volume 1. - 1045s. with with with"

Claims (1)

The formula of the invention The method of surgical treatment of patients with pancreatic head cancer complicated by duodenal stenosis, which includes decompressive percutaneous transhepatic cholangiohepaticostomy, which differs in that the cholangiohepaticostomy is transformed into an extracorporeal allogeneic biliodigestive shunt, for which a gastrojejunoanastomosis with an interloop junction according to Brown is performed, the loop of the jejunum is excluded by an aboral anastomosis according to Roux, it is fixed to the parietal abdomen, through 5p After the wound in the abdominal wall, a tubular drain is inserted into the excluded loop and connected to a cholangiohepaticostomy drain to create an extracorporeal biliodigestive shunt that drains bile into the intestines. R 60 b5