RU2632767C1 - Method for forming pancreatointestinal anastomosis in pancreatododuodenal resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: when performing the reconstructive stage of pancreatoduodenal resection after disconnection of the small bowel loop by the Roux, the loop of the small bowel is formed around the stump of the pancreatic gland. Two adjacent fixed stitches are performed on the posterior leaf of the parietal peritoneum in the zone of the lower edge of the PG on the border of the mobilized part of the stump, at a distance of not more than 1 cm. Three of the four ends of threads with needles lead to the "window" of the mesentery. A serous-muscular interrupted stitch is put by two of them between the ends of the small bowel loop. Two separate semipurse-string sutures of each of the remaining threads are made along the mesovarian edge of the small bowel loop on opposite sides of the loop until the projection of the upper edge of the PG stump. At the upper edge of the PG stump, a stitch is put on the parietal peritoneum leaf. The serous-muscular interrupted stitch is tightened between the ends of the small bowel loop. The ends of the threads are the tightened and fixed in doses. The PG duct is isolatedly stitched into the wall of the diverting section of the small bowel loop. The sides of the loop are stitched together without formation of an enteroenterostomy.

EFFECT: allows to reduce the risk of postoperative complications, the anastomotic dehiscence.

1 ex, 6 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used in abdominal surgery when performing the reconstructive stage of pancreatoduodenal resection (PDR).

PDR is the main radical surgical intervention indicated for patients with malignant diseases of the organs of the biliopancreatoduodenal zone. In addition, PDR is often performed by patients suffering from chronic pseudotumor pancreatitis. Currently, there is a steady increase in the incidence of pancreatic cancer (pancreas). Over a 10-year period, the incidence of pancreatic cancer in Russia increased from 9.21 per 100,000 of the population in 2003 to 10.69 per 100,000 of the population in 2013 (M.I. Davydov et al., 2011, A.D. Kaprin and et al., 2015). In turn, the incidence of chronic pancreatitis in the economically developed countries of Europe over the past decade has increased and amounts to 8.2-27.4 per 100,000 population (E.I. Halperin et al., 2011). Thus, with an increase in the number of patients with diseases of the periampicular zone, the number of surgical interventions, in particular, PDD, performed by this category of patients is growing. Mortality after PDD in recent years has undoubtedly decreased and amounts, according to various authors, from 0 to 7.4%. However, the complication rate remains at a high level and ranges from 17.2 to 66.6% (V.I. Onopriev et al., 2005, Yu.I. Patyutko et al., 2007, V.I. Egorov et al., 2008, R.I. Rasulov et al., 2013, A.R. Propp, 2013, M.L. Rogal et al., 2014). The overwhelming majority of cases of unsatisfactory results of PDD are still associated, despite the numerous proposed technical solutions, with complications from the pancreatic stump and anastomosis with it. Thus, the incidence of acute postoperative pancreatitis of the stump reaches 29.1% (V.I. Onopriev et al., 2005). Acute destructive pancreatitis develops in 1.3-14.3% of cases (V.I. Onopriev et al., 2005, V.I. Egorov et al., 2008, A.Yu. Popov et al., 2014). The insufficiency of pancreatodigestive anastomosis is from 0 to 22.2% (V.I. Onopriev et al., 2005, Yu.I. Patyutko et al., 2007, V.I. Egorov et al., 2008, R.I. Rasulov et al., 2013, A.R. Propp, 2013, M.L. Rogal et al., 2014). Pancreatic fistulas occur in 1.3-10.5% of cases (V.I. Onopriev et al., 2005, Yu.I. Patyutko et al., 2007, R.I. Rasulov et al., 2013, A.R. . Propp, 2013). Thus, when performing PDD, the main problem remains the treatment of the pancreatic stump and the formation of an anastomosis with it. Currently, more than 80 different methods for the formation of pancreatoenteroanastomosis (PEA) have been proposed. It follows that the standard has not yet been developed and the improvement of surgical technique is especially relevant (M.L. Rogal et al., 2014). Particular difficulty arises with the so-called "difficult" pancreatic cult, in the case of the presence of "juicy", "loose", without signs of pancreatic parenchyma fibrosis. In this situation, PEA is widely used with the so-called wide peritonization of the anastomotic zone and cut of the pancreatic stump with serous cover of the jejunum loop.

There is a method of forming pancreatic enteric anastomosis between the pancreatic stump and the small intestine of the "end to side" type with wide peritonization of the anastomosis zone with the serous cover of the adducting loop of the small intestine according to A.A. Shalimov (Onopriev V.I., Korotko G.F., Rogal M.L., Voskanyan S.E. Pancreatoduodenal resection. Aspects of surgical technique, functional consequences. Krasnodar: LLC “Quality”, 2005. - 135 pp.). Moreover, to create an anastomosis, the author uses nodal sutures that penetrate the pancreas parenchyma, which is accompanied by additional trauma to the pancreas and increases the risk of postoperative stump pancreatitis and PEA failure. With additional peritonization of PEA, the author does not conduct a pancreatic stump into the “window” of the mesentery of the loop of the small intestine, but imposes U-shaped submersible and half-net sutures on the adducting loop of the small intestine, which can lead to significant bowel deformation of the double-barrel type and contribute to prolonged enterostasis in this area with the occurrence of reflux into the pancreatic duct and, therefore, postoperative pancreatitis.

A known method of forming pancreatic intestinal anastomosis according to V.I. Onopriev et al. (USSR copyright certificate No. 1082406) (Rogal M.L., Yartsev P.A., Vodyasov A.V. Conceptual pancreatoenteroanastomosis with pancreatoduodenal resection. Ann. chir. hepatol. 2014; 19 (2): 14-17.). Before the formation of the anastomosis, the authors additionally mobilize the pancreatic stump to a distance of 2.5-3 cm, separating it from the splenic artery and vein, the pancreatic duct is isolated from the stump to a length of 1.2-1.3 cm, the stump section is sutured with sutures with a comparison front and back surfaces of the pancreas. The stump of the pancreas is carried out into the “window” of the mesentery of the loop of the small intestine with the formation of a serous channel peritonizing the anastomotic zone, while the fixation and outlet sections of the loop of the small intestine are carried out by separate nodular gray-serous sutures at the lower edge of the pancreatic stump. Next, the walls of the adducting and outlet sections of the loop of the small intestine are widely dissected around the entire perimeter. The pancreatic duct is sutured into the lead and discharge sections of the loop of the small intestine with the formation of a wide inter-intestinal anastomosis.

The disadvantage of this method of forming an anastomosis is the need to mobilize the pancreatic stump from the place of its intersection in the direction of the tail by at least 2.5-3 cm. And additional discharge from the duct stump to a length of 1.2-1.3 cm. Such mobilization is accompanied additional trauma to the gland, the need to separate its parenchyma from the trunk of the splenic artery and vein with ligation of small vessels over a specified length, which leads to additional ischemia and increases the risk of postoperative pancreatitis ti. Also, as in the previous analogue, the authors use sutures penetrating the pancreas parenchyma when suturing the wound surface of the pancreatic stump, which is associated with additional organ trauma. We consider it a drawback to stitch the pancreatic duct into the inferior and abdominal parts of the loop of the small intestine with the formation of a wide inter-intestinal anastomosis, since the risk of anastomotic failure increases due to the aggressive action of pancreatic juice on an extended suture line and high probability of reflux of the intestinal contents into the pancreatic duct from the leading part of the small intestine loop with the development of pancreatitis.

The closest analogue is considered the method of forming pancreatic enteric anastomosis according to V.F. Kasatkin et al. (RF Patent No. 2155000), including conducting a pancreatic stump through an opening in the mesentery of the small intestine, forming a serous canal around the pancreas stump from the wall of the loop of the small intestine by applying a circular purse string suture to its mesenteric edge. The retention of the pancreatic stump in the anastomosis is provided by two interrupted sutures superimposed on the posterior sheet of the parietal peritoneum by holding a ligature at the upper edge of the pancreatic stump under the purse string suture, at the lower one, under the second and penultimate stitches of the purse string suture. The fixing threads are tied so that the string of the purse-string suture freely slides under the nodes of the fixing ligatures. The purse string suture is tightened to a tight fit with the serous membrane of the intestine of the pancreatic stump. The intestinal wall is dissected on both sides of the pancreatic duct, then the edges of the pancreatic duct are sequentially sutured with the adjacent semicircles of the holes formed in the lead and outlet segments of the small intestine loop and the lateral walls of the holes in the lead and outlet segments of the small intestine loop, forming at this is a small intestinal anastomosis. This method, in contrast to the above analogues does not provide for the imposition of the formation of anastomosis of sutures that penetrate into the parenchyma of the pancreatic stump, therefore, it is devoid of the disadvantages associated with their use. However, it seems insufficiently reliable to maintain the pancreatic stump in the anastomosis by indirectly fixing the circular purse string suture through the application of two interrupted sutures to the posterior parietal peritoneum, held under the string of the purse string suture so that the filament of the purse string suture freely slides under the nodes of the fixing ligatures. “Relief” of ligatures and, as a result, increased mobility of the formed loop of the small intestine around the pancreatic stump with the possibility of migration are not ruled out. As mentioned above, we consider it a drawback to stitch the pancreatic duct simultaneously into the inferior and diverting sections of the loop of the small intestine with the formation of any variant of the intestinal anastomosis, since the risk of anastomotic failure increases due to the aggressive action of pancreatic juice on the suture line and the high probability of intestinal contents reflux into the pancreatic duct from the leading part of the loop of the small intestine with the development of pancreatitis.

Objectives of the invention: to prevent the development of postoperative pancreatitis of the pancreatic stump and the failure of pancreatic enteric anastomosis, to improve the results of surgical treatment of patients with diseases of the periampicular zone in case of PDD, to reduce postoperative complications, often leading to mortality.

The essence of the invention: it is proposed after preliminary disconnection of the loop of the small intestine along the Py loop to form a loop from the small intestine around the pancreatic stump: on the posterior sheet of the parietal peritoneum in the area of the lower pancreatic stump at the border of the mobilized part of the pancreatic stump, at a distance of no more than 1 cm, two adjacent fixed a stitch, three of the four ends of the threads with needles are brought out to the “window” of the mesentery, two of them impose a sero-muscular nodal suture between the “muffled” and free ends of the loop of the small intestine without tightening it, then perform two separate half-mesh sutures of each of the remaining threads along the mesenteric edge of the loop of the small intestine on opposite sides of the loop to the projection of the upper edge of the pancreatic stump; in the area of the upper edge of the pancreatic stump, a stitch similar to the stitch at the lower edge of the pancreatic stump is applied over the posterior leaf of the pancreatic stump, and then tightened the serous-muscular nodal suture between the “muffled” and the free ends of the loop of the small intestine, then dosed, by pulling and fixing the ends of the threads, provide an optimal fit to the serous membrane of the thin loop the intestines of the pancreatic stump, the pancreatic duct are sutured in isolation into the wall of the outlet section of the loop of the small intestine and the sides of the loop are sutured together without the formation of a small intestinal anastomosis.

The technical result was achieved by sparing mobilization of the pancreatic stump at a distance of not more than 1 cm from the edge of the cut and, after application of the pancreatic anastomosis on the loop of the small intestine disconnected along the R, with the formation of a loop around the pancreatic stump with the aim of wide peritonization of the anastomosis zone without the use of sutures penetrating the parenchyma The pancreas, in order to exclude additional trauma to the organ parenchyma, to provide more reliable fixation of the loop of the small intestine around the pancreatic stump, by performing two separate half-mesh sutures, along the mesenteric edge of the loop of the small intestine and fixed directly by the sutures themselves behind the posterior sheet of the parietal peritoneum in the area of the upper and lower edges of the pancreatic stump, which excludes the possibility of migration of the formed “cuff” around the pancreatic stump, the isolated stitching of the pancreatic duct into the outlet section of the loop of the small intestine and stitching the sides of the loop between each other without the formation of a thin-intestinal anastomosis and the risk of reflux of intestinal contents from the leading part of the loop into the pancreatic duct. As a result, the development of postoperative pancreatitis of the pancreatic stump and the failure of pancreatic enteric anastomosis is prevented, the results of surgical treatment of patients with diseases of the periampicular zone are improved in case of PDD, postoperative complications and mortality are reduced.

For a better understanding of the method, Fig. 1-6, where Fig. 1 is a schematic view of the pancreas after resection of its head; fig. 2 - pancreatic stump held in the “window” of the mesentery of the loop of the small intestine; fig. 3 - the imposition of a second half-mesh suture along the mesenteric edge of the loop of the small intestine; fig. 4 is a view of the loop of the small intestine after tightening the half-mesh sutures and nodular sero-muscular suture around the pancreatic stump; fig. 5 is a diagram of a formed pancreatic intestinal anastomosis; fig. 6 - intraoperative view of the formed anastomosis, where p. 1 - fixed stitches for the posterior sheet of the parietal peritoneum in the area of the lower edge of the pancreatic stump; p. 2 - sero-muscular nodal suture in the mesenteric region at the border of the “window” of the mesentery between the “muffled” and free ends of the loop of the small intestine; p. 3 - a serous-muscular semi-ketal suture around the mesenteric edge of the loop of the small intestine from the projection of the lower edge to the upper edge of the pancreas with enveloping the posterior surface of the pancreatic stump; p. 4 - the second sero-muscular semi-cetic suture along the mesenteric edge of the loop of the small intestine, superimposed by the end of the suture thread that is not carried out in the “window” of the mesentery, from the projection of the lower edge of the pancreas to the upper “outer” side of the loop with enveloping the front surface of the pancreatic stump; p. 5 - view of the dissected wall of the outlet free section of the loop according to the diameter of the duct with the application of the precision end-to-side virsungoyoyunoanastomosis in the variant “mucosa to mucosa”; p. 6 - nodular sero-muscular sutures on the front wall of the "muffled" and free sections of the loop of the small intestine without the formation of a small-intestinal anastomosis.

The method is carried out as follows: after removal of the organocomplex, including the head of the pancreas (pancreas), distal section of the common bile duct, duodenum, a loop of the small intestine is cut off according to Ru to superimpose an atraumatic precision virsungoyunoanastomosis with wide peritonization of the stump of the pancreas. The loop is carried out to the upper floor of the abdominal cavity through the formed “window” in the avascular zone of the mesentery of the transverse colon, to the right of the middle colonic vessels. Preparation of the pancreatic stump for anastomosis includes gentle mobilization of not more than 1 cm from the edge of the slice, precision hemostasis of all bleeding vessels of the slice of the pancreatic stump. Next, two stitching sutures are applied (PDS 0000 on atraumatic needles in an amount of 2 per thread) for the posterior leaf of the parietal peritoneum in parapancreatic tissue, without suturing the pancreatic parenchyma, in the area of the lower edge of the pancreatic stump, on the border of the mobilized part, departing from the edge of the cut no more 1 cm - step 1. The stitched threads are knotted, getting fixed stitches, and the suture is tightened after the threads are divided into two equal sections along the length - step 1. In the avascular zone of the mesentery of the jejunum loop disconnected along the Ru, departing from the “muffled about "the end of the intestine about 3-4 cm, form a" window ", equal in diameter to the pancreatic stump. Then, through the formed “window” in the mesentery, a pancreatic stump and three of the four ends of the stitching threads are carried out. Then, two of the three ends of the threads impose a sero-muscular nodal suture in the mesenteric region at the border of the “window” of the mesentery between the “muffled” and free ends of the loop of the small intestine. The suture is not temporarily tightened - p. 2. The other remaining end of the suture thread is applied around the circumference of the mesenteric edge of the loop of the small intestine with a serous-muscular half-netted suture from the projection of the lower edge of the pancreas to the upper with enveloping the posterior surface of the pancreatic stump - paragraph 3. After reaching the projection of the upper edge The pancreas thread is brought “out” from the anastomosis zone towards the tail of the pancreas. Next, a second serous-muscular semi-cetic suture is applied along the mesenteric edge of the loop of the small intestine with the end of the stitching thread that is not carried out into the “window” of the mesentery, from the projection of the lower edge of the pancreas to the upper from the “outer” side of the loop with enveloping the front surface of the pancreatic stump - p. 4. The last needle injection is carried out in the area of the upper edge of the pancreatic stump behind the posterior sheet of the parietal peritoneum in the parapancreatic tissue, without suturing the pancreatic parenchyma. Two superimposed separate half-mesh seams are not temporarily tightened. Next, along the circumference of the pancreatic duct (PAP), individual piercing threads are applied (depending on the diameter, but not less than 5 with a narrow PAP, with a PDS 0000 thread on an atraumatic needle). Then, in turn, at first they tighten the previously applied sero-muscular nodal suture at the border of the mesentery window between the “muffled” and free ends of the loop of the small intestine, then in the area of the upper edge of the pancreatic stump two half-mesh sutures are tightened, dosed, to the optimal fit with the serous membrane of the intestinal stump Pancreas Thus, coverage of the pancreatic stump with the serous membrane of the jejunum wall with the formation of the serous channel is achieved. Next, opposite the PCA, the wall of the abduction free section of the loop of the small intestine is cut along the diameter of the duct. The precision end-to-side virsungoyejunoanastomosis is applied in the “mucosa to mucosa” variant - step 5. Then separate nodular serous-muscular sutures are placed on the front wall of the “muffled” and free sections of the loop of the small intestine without the formation of a thin-intestinal anastomosis - step 6 Thus, the formation of a precision virsungoyeunoanastomosis is achieved with additional complete atraumatic peritonization of the entire section of the pancreatic stump, without capturing the organ parenchyma in the sutures - p. 6.

Example. Patient M., 58 years old, was hospitalized as planned in the surgical department No. 1 of GBUZ Regional Clinical Hospital No. 2 of Krasnodar 04/22/2016 with a diagnosis of Cr head of the pancreas T1N0Mx, I st., II class. gr .. From the anamnesis: from 03/28/2016 to 04/04/2016 I was hospitalized in the same department with a diagnosis of Cr head of the pancreas T1N0Mx, I st, II class. gr .. Obstructive jaundice. Performed endoscopic retrograde papillosphincterotomy, retrograde cholangiography, stenting of the common bile duct. After conservative therapy, against the background of positive dynamics, she was discharged for outpatient treatment. Re-hospitalization after stopping the clinical manifestations of obstructive jaundice and normalization of bilirubinemia. After completion of the preoperative examination and preoperative preparation of the patient, the surgical intervention was performed on April 25, 2016: upper midline laparotomy. During the audit of abdominal organs, a pancreatic head tumor was found up to 1 cm in diameter, the body and tail of the pancreas were of normal elasticity, lobation was preserved, and there were no signs of fibrosis. No metastases have been detected. Regional lymph nodes are not enlarged. Performed pancreatoduodenal resection with preservation of the pylorus. Wirsung duct is not expanded, with a diameter of up to 2 mm. The recovery phase: to the loop of the small intestine disconnected along the Ru, drawn to the upper floor of the abdominal cavity through the formed “window” in the avascular zone of the mesentery of the transverse colon, to the right of the middle colonic vessels, an atraumatic precision virsungoyunoanastomosis with wide peritonization of the slice gland is first formed the above methodology. An end-to-side choledochojejunoanastomosis of atraumatic PDS 0000 filaments was formed 20 cm more distal. An end-to-end duodenojejunoastomosis was formed with separate PDS 0000 interrupted sutures, an end-to-side inter-intestinal anastomosis was formed 40 cm distal. The mesentery windows were sutured. Hemostasis. Abdominal drainage. Layered suture of the wound. Aseptic dressing. The postoperative period was uneventful. The assessment of the formed pancreatic intestinal anastomosis was carried out on the basis of the criteria of the International Study Group on Pancreatic Fistula - ISGPF, according to which there were no signs of insolvency. There were no other complications of the postoperative period (the development of postoperative pancreatitis of the pancreatic stump, the formation of pancreatic fistula, fluid accumulations of the abdominal cavity, abscesses of the abdominal cavity, suppuration of the postoperative wound, prolonged gastrostasis, etc.). 05/11/2016 a patient in satisfactory condition was discharged for outpatient treatment at the place of residence.

The developed method for the formation of pancreatic enteric anastomosis in pancreatoduodenal resection was tested in 14 patients with positive results. There were no cases of death, insolvency of the pancreatic enteric anastomosis, or the development of pseudoperative pancreatitis of the pancreatic stump.

Claims (2)

A method of forming pancreatic enteric anastomosis in pancreatoduodenal resection, including conducting a pancreatic stump (pancreas) through a “window” in the mesentery of the small intestine, forming a loop from the small intestine around the pancreatic stump, characterized in that after the formation of a loop of the small intestine disconnected along the Roux, the pancreas is stumped in A “window” of the mesentery of the small intestine, onto a piece of parietal peritoneum in the area of the lower edge of the pancreas at the border of the mobilized part of the pancreatic stump, at a distance of not more than 1 cm, two adjacent fixed stitches , three of the four ends of the filaments with needles are brought out to the “window” of the mesentery, then two of the three filaments impose a sero-muscular nodal suture between the “muffled” and diverting ends of the loop of the small intestine, with the remaining thread put on the mesenteric edge of the loop of the intestine, a half-cerous serous-muscular muscle a seam from the lower edge to the upper edge of the pancreas with enveloping the posterior surface of the pancreatic stump, the second half-mesh seam is laid with the end of the thread not drawn into the “window” of the mesentery, from the lower edge of the pancreas to the upper with enveloping the front surface of the pancreatic stump, at the upper the edges of the pancreatic stump make an injection into the leaf of the parietal peritoneum, and both superimposed serous-muscular sutures are tightened without suturing the parenchyma of the pancreas to the optimal fit with the serous membrane of the intestine of the pancreatic stump, after which the suture is tightened between the “muffled” and diverting ends of the loop of the small intestine at the lower edge of the pancreatic stump , provide optimal stump fit by the serous membrane of the intestine, the pancreatic duct is separately sutured into the wall of the outlet section of the loop of the small intestine; the sides of the intestinal loop are sutured together without the formation of a small intestinal anastomosis. .

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