RU2260385C1 - Method for surgical treatment of duodenal leiomyomas of peripapillary localization - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should perform widened mobilization of pancreatoduodenal complex followed by precise radical resection of pathological focus. In case of uncomplicated flow it is necessary to perform extramucous resection of the tumor, in case of complicated flow one should remove the tumor by resecting corresponding layers of duodenal wall and papilla.

EFFECT: improved functional results of surgical therapy.

27 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of leiomyomas of the periopapillary localization of the duodenum.

Organ-preserving surgical interventions for leiomyomas near the most important anatomical structures, in particular the large duodenal papilla, are one of the most difficult sections of abdominal surgery, due to the anatomical complexity of this zone.

A significant arsenal of methods for surgical treatment of patients with benign non-epithelial neoplasms of the large duodenal papilla, lack of common tactics, and dissatisfaction with the long-term results of treatment led to the search for highly effective technologies.

The method of surgical treatment of leiomyomas of the large duodenal papilla described in the article “Benign tumors of the large duodenal papilla” was taken as an analogue. S.A.Shalimov, A.P. Radzikhovsky, M.E. Nichitailo. Clinical Surgery, No. 11, 1984, p. 33, when the diameter of the benign neoplasm exceeds 1.5 cm, the authors propose pancreatoduodenal resection.

The disadvantages of the method are:

1. extensive resection of the duodenum, pancreatic head with a powerful sphincter apparatus of the bile duct;

2. violation of the natural passage of the food chyme and the secrets of the liver and pancreas through the digestive tube;

3. a high percentage of postoperative complications due to the development of the inflammatory process from the biliary tract.

As a prototype of the proposed method, the method of radical duodenoplasty of complicated duodenal ulcer complicated by duodenal ulcers described in the atlas-monograph “Etudes of functional surgery of peptic ulcer” V. I. Onopriev was adopted. Krasnodar, 1995, pp. 201-203 (Fig. 147-157).

The method of radical duodenoplasty involves excising only a pathological lesion, in particular a complicated duodenal ulcer, and conducting bridge-like duodenoplasty with preservation of the neuromuscular duodenal bridge, thereby ensuring removal of the pathological lesion with subsequent restoration of the integrity of the duodenal wall.

The disadvantages of this method are:

1. The risk of damage to the common bile duct and Wirsung duct;

2. insufficient mobilization of the pancreatoduodenal complex, limiting the possibility of surgical intervention on the papillary region of the duodenum;

3. the risk of acute pancreatitis.

Objectives of the invention:

1. development of optimal access to the affected area;

2. maximum preservation of intramural vascular and nerve connections of the duodenum;

3. improving the functional results of surgical treatment for leiomyomas of the periopapillary localization of the duodenum.

The technical essence of the invention and the novelty is that for optimal access to the affected area of the duodenum, the steps of expanded mobilization of the pancreatoduodenal complex are performed: the colonic-hepatic ligament is completely crossed, the hepatic colon of the colon is widely mobilized and the right half of the omentum is opened from the colon in front of the colon with pancreas, mesentery colon of the colon on the right, vertical and descending horizontal branches of the duodenum intestines, to the root of the mesentery of the small intestine, cross the duodenal-renal ligament and separate the pancreatoduodenal block together with the retroperitoneal tissue, to the level of the superior mesenteric artery with complete exposure of the inferior vena cava, the fascial case of the lower horizontal loop of the duodenum 1.5 -2.0 cm, on the left they cross the ligament of the Treitz and the connective tissue cords surrounding it, preserving the intramural vascular and nerve connections of the duodenum, they carry out a radical, precision ud Leniye pathological focus: with uncomplicated neoplasm operate vneslizistoe tumor removal and in complicated - removal of the tumor excision operate with the respective layers of the bowel wall and papilla.

This allows you to restore adequate passage through the duodenum, the outflow of bile and pancreatic secretion, save the sphincters of the large duodenal papilla, significantly improve immediate and long-term functional results, and reduce the likelihood of developing acute pancreatitis when removing leiomyomas of the periopapillary localization of the duodenum.

The method is as follows.

Access is performed in the amount of extended upper mid laparotomy. To create access to the duodenum, wound aperture is corrected with Sigal-Kabanov type expanders. The angle of traction and compression of the costal arch with the retractor should be perpendicular to the costal arch. In this case, the right costal arch rises and is compressed with dislocation of the sterno-costal joint, and the left costal arch is only held by the second elevator. A skin incision and an aponeurosis incision are performed with the intersection of the ligaments going from the xiphoid process to the costal arch, to the costal-sternal joint, and in all cases is accompanied by dislocation of the latter.

The duodenum is mobilized with paraduodenal fiber according to the method of Professor V.I. Onopriev. The mobilization level in all cases is from the hepatoduodenal ligament to the duodenojejunal transition. Before mobilization, retroperitoneal tissue was infiltrated in the area of the duodenum and pancreatic head with a solution comprising a 0.5% solution of novocaine, polyglucin, antibiotics, and acinar cell inhibitors. The technology of mobilization of the duodenum includes the mandatory preservation of the connective tissue case around the intestine and, most importantly, the paraduodenal tissue, which provides mobility of the walls of the duodenum.

Access to the pancreatoduodenal complex is created. For this, a wide mobilization of the right half of the colon is performed. The main stages of the expanded mobilization of the pancreatoduodenal complex include the following.

1. Complete intersection of the colonic-hepatic ligament, wide mobilization of the hepatic angle of the colon and separation of the right half of the greater omentum from the colon. Opening in front of the head of the pancreas, the root of the mesentery of the colon on the right, the vertical and descending horizontal branches of the duodenum, to the root of the mesentery of the small intestine.

2. The intersection of the duodenal-renal ligament and the separation of the pancreatoduodenal block together with retroperitoneal tissue, to the level of the superior mesenteric artery and with complete exposure of the inferior vena cava.

3. The intersection of the fascial case of the lower horizontal loop of the duodenum along its lower edge, retreating 1.5-2.0 cm. The fascial case of the latter is represented by the anterior fascia descending from the front surface of the pancreatic head and the posterior descending onto the duodenum from the back surface pancreatic heads. Both fascias are connected along the mesenteric edge of the horizontal loop and leave as a single leaf (Doldi's fascia, which provides mobility of the walls of the duodenum) to the retroperitoneal fascial formations of the right kidney, inferior vena cava and aorta.

4. Further, on the left we cross the ligament of the Treitz and the connective tissue cords surrounding it, additionally holding the duodenojejunal angle. Local infiltration is performed with a combined solution of retroperitoneal fiber under the capsule of the pancreas.

Such a wide mobilization is necessary precisely in order to freely divert the colon to the left with the root, to exclude tension over the right colon vein and its separation from the superior mesenteric vein. We mobilize the right corner of the colon with an omentum. Further, the right half of the greater omentum is separated from the right half of the colon with the preservation of blood supply to the omentum, because this part of the greater omentum is subsequently used for the identification of the mobilized part of the duodenum.

Advanced surgical technology for intraoperative research is necessary to study the histotopography of the tumor and involves tracing the course of important anatomical structures on approaches to the leiomyoma, including extraorgan nerves and blood vessels. Photo 1 (I, II).

A distinctive feature of leiomyomas, which determines its clinical course and distinguishes it from other types of neoplasms, is expansive growth. When the interwoven muscle fibers of a tumor (Photo 5-XX), having a random, random arrangement, push apart the adjacent layers of the duodenal wall as the tumor grows, causing trophic disturbances in them. Thus, it is not germination that occurs, but mechanical compression of the surrounding structures, which actually form the so-called “false capsule”.

It should be noted that the nature of macroscopic changes is determined by the degree of damage to the “false capsule”. This explains that in all cases there is a lack of a visible adhesive process, inflammatory edema, and the mobility of the wall of the large papilla of the duodenum is preserved. It was possible to identify the neoplasm by various deformations of the shape and size of the wall of the duodenum with a volumetric intra-wall formation.

The preservation of the mobility and displacement of the large papilla of the duodenum in the tumor area also explains that stenosis of the lumen of the intestine was not observed in any case, despite the significant (more than 5 cm) size of the neoplasm.

Thus, the nature of pathomorphological changes in the area of localization of leiomyoma is determined by the degree of ischemia. Mechanical pressure is directly affected by the intestinal mucosa. In the initial stage, this is a thinning of the mucosa, and if the tumor continues to grow, ulceration. In this case, the stage of complications sets in, with clear macroscopic signs of the inflammatory process and accompanied by the development of dystrophic necrobiotic processes, both directly in the area of contact of the tumor with the external environment and from the surrounding tissues, namely directly in the mucous membrane, while the mucous membrane is intact with ischemia, limited to a powerful granulation shaft along the edge of the ulceration. At the same time, a lymphoproliferative reaction is observed from the lymphatic system, which is manifested by regional lymphadenopathy.

Next, carry out the stage of radical removal of smooth muscle neoplasm. To confirm the obtained data of surgical intraoperative research, modern high-precision and most informative instrumental methods are used.

Under transillumination (endoscopic) and ultrasonographic control, a study of angioarchitectonics and tumor borders is carried out, the topographic and anatomical relationship of the tumor to the wall layers of the large papilla of the duodenum, and the distance from the mouth of the small papilla are specified. A detailed study of the head of the pancreas, the trajectory of the main pancreatic duct, the intrapancreatic part of the common bile duct, the ampulla of the large papilla allows not only to reveal the degree of structural and functional changes in the latter, but also to carry out a complex of powerful preventive manipulations aimed at preventing and treating possible intra- and postoperative disorders from the side pancreatoduodenal complex. The use of ultrasound dopplerography allows you to locally assess the degree of blood supply to the involved layers of the intestinal wall and the severity of trophic disorders, to identify the main vascular stems entering the tumor and exiting.

The data obtained are compared with the data of preoperative studies. Thus, the algorithm of the volume of surgical intervention is determined.

So, in the uncomplicated course of the neoplasm, when there are no phenomena of the involvement of the mucous and submucosal layers in the pathological process, which is confirmed by the data of endoscopic and ultrasonographic studies, extra-mucous tumor removal is performed. In this case, the muscular layer of the duodenal wall undergoes the most pathomorphological changes. Figure 1, 2, 3, 4 (1 - the posterior lower pancreatoduodenal artery; 2 - the BDS ampoule from the side of the posterior wall of the duodenum; 3 - the tumor; 4, 5 - the superior mesenteric vessels; 6 - the prepared muscle layer of the posterior wall of the DIC; 7 - mouth of the BDS; 8 - serous-muscular suture; 9 - matching sutures at the level of the BDS ampoule; 10 - suture line of the posterior wall of the duodenum). Removal of the neoplasm is controlled by the preserved submucosal layer.

In a complicated clinical course (the presence of ulceration at the top of the tumor, interest in the main process of the muscle, submucosal and mucous layers of the wall of the large duodenal papilla, confirmed by ultrasonographic studies), the serous membrane is cut with a bordering incision. Layered preparation of the wall of the duodenum, respectively, of the location of the tumor, allows you to clarify the nature of the growth of the tumor. Simultaneously evaluate the nature of macroscopic changes in each layer of the intestine. Excision of the neoplasm is performed with precision, which implies the maximum preservation of functionally and structurally complete tissues of the intestinal wall. In the subserous layer, the nature of pathomorphological changes is less pronounced, since the muscle fibers of the tumor push apart the tissues of the directly muscle and submucosal layers, which led to ulceration of the intestinal mucosa.

Dissection of the mucous membrane of the duodenum is carried out in the "border" zone corresponding to the place of transition from the scar-transformed mucous and submucosal layers to the full, sufficiently blood supply layers of the intestinal wall.

Due to the spread of the scar-transformed mucous and submucosal layers covering the tumor on the wall of the large duodenal papilla, tumor removal is performed with excision of the corresponding layers of the intestinal wall and papilla. The tumor is removed. The restoration of the continuity of the duodenum is carried out by adaptation of the layers of the same name.

In order to adequately decompress the bile and pancreatic ducts, in all cases, the drainage of the Wirsung duct is performed according to the clinic technique. 11, 12, 13, 14 (11 - ulceration of the mucous membrane at the apex of the tumor; 13 - suture of the anterior semicircle of the duodenum; 17 - suture of the posterior wall of the duodenum; 19 - button probe was inserted into the choledochus through the mouth of the large duodenal papilla; 20 - drainage Wirsung duct; 21 - excised mucous and submucosal layers of the ampoule of the large duodenal papilla; 22 - adaptive suture of the wall of the large duodenal papilla and duodenum).

In two cases, leiomyoma of the large papilla of the duodenum is considered, from the side of the anterior and posterior walls, respectively.

In the first case, after opening the anteromedial wall of the duodenum, a round, with smooth contours, intact mucous membrane is revealed, the formation of a large papilla, the upper edge of which does not reach the small papilla of the duodenum of 8 mm.

Fig. 15 (7 - mouth of the large papilla, 3 - leiomyoma, 13 - upper anterior pancreato-duodenal artery, 25 - skeletonized sections of the small and large papilla, 23, 26 - suture-holders of the anterior and medial walls of the intestine, 24 - mouth of the small papilla )

The mouth of the large papilla is not deformed. Its mucous membrane smoothly passes to the base of the tumor, and immediately above the leiomyoma that swells into the lumen of the intestine, it looks like a thinned film. The muscular structure of the large papilla, in the projection of the location of the leiomyoma, is represented by a thinned layer, which gradually, outside the tumor zone, passes into the unchanged layers of the intestine and does not undergo significant changes, with the exception of the developed vascular network, repeating the outline of the tumor, which involves the implementation of organ-preserving surgery.

After dissection of the lesser curvature of the duodenum, sections of the small and large papillae are skeletonized along the path of their entry into the intestinal wall. Fig. 16 (15 - ligated branches of the upper anterior pancreatoduodenal artery, 21 - the exposed wall of the ampulla of the large papilla after removal of the tumor, 27 - the medial wall of the duodenum, 28 - intact mucosa of the large papilla).

The mucous membrane covering the tumor is opened around the circumference of the neoplasm and then widely isolated within the muscle wall. The tumor is removed from the underlying anterior wall of the ampulla of the large papilla, corresponding to the described pathomorphological changes. Plastic surgery is performed by sero-muscular-submucosal sutures with absorbable monofilament, according to the method described above.

In the 2nd case, the tumor is located on the posterior wall of the large papilla of the duodenum. Fig. 17 (29 — posterior wall of the duodenum, 30 — naked muscle wall of the large papilla, 31 — posterior medial wall of the intestine, 32 — ligated branches of the posterior pancreatoduodenal artery). The small curvature of the intestine is mobilized, then the intrapancreatic part of the choledoch is prepared, before it enters the wall of the intestine, and the terminal part of the Wirsung duct. The duodenum is opened from the posteromedial wall. Removal of the neoplasm occurs along the edge of the muscle layer of the large papilla. Restore the integrity of the back wall with a precision seam.

In a situation where there are changes in the muscle layer of the posterior wall of the ampulla of the large papilla in the region of the leiomyoma, the tumor is removed within the normal tissue of the wall of the papilla. Fig. 18. When performing plastic surgery, the edges of the incision of the large papilla are adapted layer by layer with the posterior wall of the duodenum.

The last step is omentoplasty of the postoperative wound. For this purpose, a dissection of a large omentum flap of sufficient length from the right half of the colon is performed. Photo 3 (XII, XIII, XIV).

Example 1

Patient K., 20 years old, was admitted to the hospital for a neoplasm of the vertical branch of the duodenum. After conducting clarifying research methods:

1. endoscopic Photo 6 A (1 - large duodenal papilla, 2 - tumor);

2. Ultrasonographic Photo 6 V (3 - the vertical branch of the duodenum, at the tumor level, 4 - the head of the pancreas, 3 - the lower horizontal branch of the duodenum);

3. X-ray - radiographs of the bulb and loop of the duodenum Photo 6 C (2 - tumor, 3 - vertical branch of the duodenum);

4. manometric, by the method of open catheters Photo 7, (manometric signs of obstructive formation in the cavity of the duodenum),

including histological, diagnosed with parapapillary leiomyoma duodenum, mixed growth. Surgical treatment performed.

Upper middle laparotomy with hardware-based access correction with Sigala-Kabanov retractor.

On palpation, along the posterior medial wall of the duodenum, a dense-elastic consistency is determined by the size of 2 × 3 cm. Figure 1. (1 - posterior lower pancreatoduodenal artery, 2 - BDS ampule from the posterior wall of the duodenum, 3 - tumor, 4, 5 - superior mesenteric vessels).

The duodenum is mobilized. Intestinal-hepatic, duodenal-renal ligaments intersect.

There are no phenomena of involvement of the mucous and submucosal layers in the pathological process, which is confirmed by ultrasonographic studies. Extralucous tumor removal is performed. Figure 2 (6 - prepared muscle layer of the posterior wall of the duodenum, 7 - the mouth of the BDS). Removal of the neoplasm is controlled by the preserved submucosal layer.

The restoration of duodenal continuity is carried out by adaptation of the layers of the same name. On the edges of the duodenal wound, sero-muscular sutures-holders are applied - two lateral, along the line, transverse to the axis of the vertical branch of the duodenum and in the middle of the proximal and distal edges. Figure 3 (8 - serous-muscular suture, 9 - matching sutures at the level of the ampoules BDS). A single-row nodular external serous-muscular-submucosal suture with 4-5 / 0 monofilament is used. Figure 4 (10 is the seam line of the back wall of the duodenum).

Omentoplasty of the wound is carried out by a strand of a large omentum. Figure 5. In order to adequately decompress the bile and pancreatic ducts, microcholecystostomy is performed.

Example 2

Patient S., 44 years old, was admitted to the hospital with a diagnosis of gastrointestinal bleeding of unknown etiology. After the examination, the diagnosis was made: parapapillary leiomyoma of the vertical branch of the duodenum, exophytic form, complicated course - ulceration, bleeding.

Surgical treatment performed.

Upper middle laparotomy with hardware-based access correction with Sigala-Kabanov retractor. Intraoperative study. In the area of the lesser curvature of the duodenum there is a bulging of the serous membrane due to intraluminal volumetric formation. In a manual study, the neoplasm has a dense texture and a converging surface on top of the tumor. 6 (7 - the mouth of the BDS, 11 - ulceration of the mucosa at the top of the tumor, 12 - "window" of the duodenum at the tumor level).

After mobilization of the duodenum, the colonic-hepatic, duodenal-renal ligaments intersect. 7 (7 - the mouth of the large duodenal papilla, crossed and bandaged branches of the upper anterior pancreatoduodenal artery, 13 - the upper pancreatoduodenal artery, 14 - mobilized pancreatic flap adjacent to the tumor, 3 - protrusion of the serous membrane due to exophytic tumor).

An ultrasonographic study was performed. It was established that the tumor originates from the muscular membrane of the posterolateral wall of the lesser curvature of the vertical branch of the duodenum, without involving the large duodenal papilla in the tumor process.

On the lower edge of the tumor, the serous membrane is dissected. The neoplasm was isolated by separating loose adhesions within the muscle and submucosal layers. Duodenotomy and mucosal resection are performed only in the zone of intimate fixation of it to the tumor. Photo 2 (III, IV, V, VI, VII). Photo 3 (VIII, IX, X, XI) shows the nature of the histological changes along the edge of the tumor, mainly the compression of the submucosal layer and the center of the tumor, respectively.

The tumor is removed. Fig (7 - the mouth of the BDS, 16 - the wall of the duodenum, after removal of the tumor). Photo 4 (XV, XVI, XVII, XVIII) shows the nature of pathomorphological changes in the submucosal and mucous layers of the intestinal wall, which corresponds to the appearance of dystrophic processes and involutional changes (vacuolization of the cytoplasm, pycnosis of the nuclei of muscle cells).

The restoration of duodenal continuity is carried out by adaptation of the layers of the same name. Fig.9 (7 - the mouth of the BDS, 17 - the defect of the posterolateral wall of small curvature of the duodenum is sutured from the lower corner of the wound with interrupted serous-muscular sutures to the level of the base of the papilla).

On the edges of the duodenal wound, sero-muscular sutures-holders are applied - two lateral, along the line, transverse to the axis of the vertical branch of the duodenum and in the middle of the proximal and distal edges. Figure 10 (18 is the seam line of the medial semicircle of the duodenum). Omentoplasty of the wound.

In order to adequately decompress the bile and pancreatic ducts, microcholecystostomy and drainage of the common bile duct are performed according to the clinic technique.

The operations of the described method were performed in 11 patients with good results. After surgery, all patients underwent:

1. endoscopic examination Photo 8 D (1 - large duodenal papilla);

2. X-ray Photo 8 E radiograph of the duodenum loop (3 - corresponds to the area of surgical intervention);

3. ultrasonographic Photo 8 F, N (3 - the vertical branch of the duodenum at the level of surgical intervention, 4 - the head of the pancreas);

4. manometric, by the method of open catheters Photo 9. The tensogram shows a periodic motor complex consisting of phases of non-rhythmic activity, rhythmic activity and rest, antropyloroduodenal coordination is preserved, functionally significant pathological signs were not revealed.

In the postoperative period, complications were not observed in any case. All patients, up to 4 months after surgery, returned to work. The quality of life indicators are significantly higher compared to the initial data, and in some cases reach submaximal values. Surgical treatment improves the quality of life of patients in all evaluated parameters.

Thus, the described method can improve immediate and long-term functional results, provides optimal access to the affected area by mobilization of the pancreatoduodenal complex, preserving the intramural vascular and nerve connections of the duodenum to the maximum, and reducing the likelihood of developing acute pancreatitis.

The implementation of the method allows you to restore an adequate passage along the duodenum, outflow of bile and pancreatic secretion, save the sphincters of the large duodenal papilla, and reduce the length of hospital stay.

Claims (1)

A method for the surgical treatment of leiomyomas of the periopapillary localization of the duodenum, including the removal of the pathological focus and restoration of the integrity of the duodenum, characterized in that the stages of expanded mobilization of the pancreatoduodenal complex are performed: the colonic-hepatic ligament is completely intersected, the hepatic and the hepatic cornea are widely mobilized from the large intestine colon with opening in front of the head of the pancreas, mesentery root of the colon to the flanks of the right, vertical and descending horizontal branches of the duodenum to the root of the mesentery of the small intestine, intersect the duodenal-renal ligament and separate the pancreatoduodenal block together with the retroperitoneal artery to the level of the superior mesenteric artery and the inferior inferior obesity and the inferior lateral foramen the edge, retreating by 1.5-2.0 cm, cross the Treytz ligament and the connective tissue cords surrounding it, preserving intramural vascular and not tied duodenum, carry out radical precision removal of the pathological focus, in case of uncomplicated neoplasm, extra-mucous tumor removal is performed, and in complicated tumor removal is performed with excision of the corresponding layers of the intestinal wall and papilla.

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