RU2217064C2 - Method for treating mechanical jaundice - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: one should carry out superior median laparotomy and develop hepaticocholecystoanastomosis by making V- shaped incision of 15 mm length from right hepatic duct through common hepatic duct onto left hepatic one. Interrupted sero-serous sutures are applied by leaving distally against lower incision's part with gallbladder's wall. V- shaped incision is performed at gallbladder. The second row of sutures is applied onto posterior lip of anastomosis. Anterior lip of anastomosis is developed with double-row interrupted sutures. Cholecystojejunoanastomosis with a loop is applied by special technique by developing invagination valve in jejunum at 10-12 cm against interintestinal anastomosis. The method enables to interrupt jaundice in case of tumor development onto choledochal area by involving cystic duct. EFFECT: higher efficiency of therapy. 7 dwg

Description

 The invention relates to medicine, surgery, specifically to methods for treating obstructive jaundice.

 Closest to the proposed is the method proposed by V. I. Kochiashvili [1], which to form an outflow of bile with a hepatic choledochus tumor with a lesion of the cystic duct formed hepatic cholecystojejunoanastomosis. In this case, the first row of the anastomosis was superimposed in the longitudinal direction along the choledoch axis between the common hepatic duct and the gall bladder. The common hepatic duct and gall bladder were cut up to 1 cm long. Then the second row of the anastomosis was superimposed, a 3-4 cm diameter drainage tube with a diameter of up to 8 mm was inserted through the hole. An anastomotic anterior lip was formed on the tube with a double-row suture. An incision was made in the bottom of the gallbladder, the drainage tube was removed. The gallbladder incision site was used to form an anastomosis between the loop of the jejunum, held behind the colon with the intestinal anastomosis according to Brown at a distance of 20 cm.

 The disadvantages of the above method was the limited scope, which was due to the insufficient length of the common hepatic duct for the formation of hepatic cholecystoanastomosis during the proliferation of the tumor and a significant number of complications with the development of reflux cholangitis.

 A new technical result - increasing efficiency by reducing complications and expanding the scope - is achieved by using a new method for the treatment of obstructive jaundice, including upper median laparotomy, revision of the pancreatoduodenal region, followed by the formation of hepatic cholecystoanastomosis, cholecystojunoanastomosis, and a 15 mm length hepaticocholecyst anastomosis is performed to form going from the right hepatic duct through the common hepatic duct to the left hepatic pro ok, impose nodular gray-serous sutures, retreating in the distal direction from the lower part of the incision with the gallbladder wall, make a V-shaped incision in the gallbladder, lay the second row of sutures on the posterior lip of the anastomosis, forming the anastomosis front lip with double-row interrupted sutures, then impose cholecystoyunoanastomosis with a loop according to Ru with the formation of an invagination valve in the jejunum at a distance of 10-12 cm from the inter-intestinal anastomosis.

 The method is as follows: perform a midline laparotomy, conduct an audit of the pancreatoduodenal zone. In an inoperable process with the spread of the tumor to the common hepatic duct involving the cystic duct or iatrogenic damage to the common hepatic duct after resection of the stomach, hepatic cholecystoanastomosis is performed, for which a 15-mm incision is made, going from the right hepatic duct through the common hepatic duct to the left hepatic duct (figure 1). Impose nodular gray-serous sutures with a distance between the sutures of 1 mm, departing 2 mm in the distal direction from the lower part of the section of the common hepatic duct with the gallbladder wall. A V-shaped incision is made 15 mm long on the gallbladder, a second row of sutures is applied to the posterior lip of the anastomosis, then the front lip of the anastomosis is formed with double-row interrupted sutures (Figs. 2, 3). Impose a cholecystoeunoanastomosis with a loop according to Ru with the formation of an invagination valve in the jejunum at a distance of 10-12 cm from the inter-intestinal anastomosis (Figs. 4-7).

 Clinical example 1. Patient K., 56 years old, was in the surgical department from 5.04.2000 to 6.05.2000 with a diagnosis of Pancreatic head cancer of the IV st. with the spread of the tumor to the common hepatic duct. Obstructive jaundice.

 He acted on an emergency basis with complaints of jaundice, weakness, malaise. 04/07/2000 after disintoxication therapy under general anesthesia, the operation is an audit of the abdominal organs, hepatic cholecystojejunoanastomosis according to the described technique. Abdominal drainage.

 In the postoperative period was carried out infusion, antibacterial and anti-inflammatory therapy, the introduction of single-group plasma.

 Ultrasound examination of the bile ducts is not expanded, there are no signs of hypertension. On the 16th day after surgery, jaundice in the patient was completely stopped. Blood bilirubin decreased to 18.4 mmol / l, no signs of purulent cholangitis. In satisfactory condition, the patient was discharged under the supervision of an oncologist at the clinic. The patient lived after surgery for 6 months, died from the progression of the tumor process, there were no signs of obstructive jaundice.

 Performing a hepatic cholecystoanastomosis with the formation of a V-shaped section with a length of 15 mm is necessary in order to be able to impose an anastomosis, especially with a narrow common hepatic duct, also with the further proliferation of the tumor in the proximal direction, this helps to preserve the outflow of bile along one of the lobar hepatic ducts. The formation of cholecystoyunoanastomosis with a loop according to Ru with an invagination valve in the jejunum at a distance of 10-12 cm from the inter-intestinal anastomosis is necessary to prevent reflux cholangitis. A distance of 10-12 cm was chosen optimal for the least shutdown of the intestinal area and the application of the anastomosis without tension.

 According to the developed technique, 5 patients with cancer of the head of the pancreas and choledoch of stage IV aged from 50 to 70 years were operated on, which allowed to improve the quality of life in this category of patients.

 In the early and late postoperative period, a comprehensive examination of patients was carried out. Ultrasound examination of the bile ducts is not expanded, well emptied, there are no signs of inflammation.

 Thus, the proposed method allows you to stop jaundice when the tumor spreads to the common bile duct with the involvement of the cystic duct, prevents the development of reflux cholangitis.

Sources of information
1. Kochiashvili V.I. Atlas of biliary tract surgery. M.: Medicine. - 1971. 208 p. (prototype).

Claims (1)

A method of treating obstructive jaundice, including upper median laparotomy, revision of the pancreatoduodenal region with the subsequent formation of hepatic cholecystoanastomosis, cholecystojunoanastomosis, characterized in that for the formation of hepatic cholecystoanastomosis, a V-shaped incision is made, 15 mm long, extending from the duct through the hepatic duct to the right liver duct impose nodular gray-serous sutures, retreating in the distal direction from the bottom of the section with the gallbladder wall, producing t V-shaped incision in the gall bladder, the second row of superimposed stitches on the back lip of the anastomosis, anastomosis front lip forming double row interrupted sutures further applied with a loop holetsistoeyunoanastomoz Roux invaginated to form a valve in the jejunum at a distance of 10-12 cm from mezhkishechnogo anastomosis.

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