Method for surgical management of chronic pancreatitis complicated by formation of pseudocysts of head, body and tail of pancreas

FIELD: medicine.

SUBSTANCE: distal pancreas resection is performed. That involves transecting a parenchyma to the right from a superior mesenteric vein. That is followed by a resection of an anterior surface of the pseudocysts of the head of pancreas. A Roux pancreatocystojejunoanastomosis with isolated enteric loop is created.

EFFECT: reduced intraoperative injuries and risk of postoperative complications, lower extent of the operation, preserved portion of the pancreatic parenchyma and physiological passage of food and bile in the gastrointestinal tract by the distal pancreas resection and created pancreatocystojejunoanastomosis with the cyst walls and the anterior surface of the head of pancreas.

1 ex

 

The invention relates to medicine, namely to abdominal surgery, and can be used during surgery for chronic pancreatitis complicated by formation of pseudocyst head, body and tail of the pancreas.

Surgical treatment of patients with chronic pancreatitis and the presence of pseudocyst remains a difficult task that often requires extensive operations on the abdominal organs. One of the possible variants of surgical treatment of chronic pancreatitis complicated by formation of pseudocyst head, body and tail of the pancreas, is a Subtotal resection of the pancreas (S. Gourgiotis, Germanos S. and Ridolfini, M. P., Surgical management of chronic pancreatitis; 2007; 6; 121-133). Surgical treatment involves the removal of the tail, body and head of the pancreas along the lateral edge of the upper anterior pancreaticoduodenal artery and suturing the stump of the organ.

The disadvantage of this method are the complexity of the operation due to the presence of pseudocyst in the cult of the body and, consequently, a high risk of developing pancreatic fistula. This complication occurs in 10-30% of cases after resection interventions on the pancreas (č F, Jon V., Subrt Ζ. et al. Pancreatic fístula - definition, risk factors and treatment options; 2013; 92(2): 77-84; Dominguez-Comesaña V., Gonzalez-Rodriques J. F., Ulla-Rocha J. L. et al. Mobidity and mortality in pancreatic resection. 2013).

Another method of treatment of this disease, more radical, is total pancreatectomy. Manipulation involves removing the whole pancreas, distal stomach, duodenum, proximal portion of the thin, distal common bile duct and spleen (Ε John. Skandalakis, Gene L. Colborn, Thomas A. Weidman, Roger S. Foster, Jr., Andrew N. Kingsnorth, Lee J. Skandalakis, Panajiotis N. Skandalakis, Petros S. Mirilas Skandalakis' Surgical Anatomy; Ch. 21, 2004). For total pancreatectomy is characterized by high volume operations, a serious post-operative complications with the development of insulin-dependent diabetes mellitus and malabsorption due to exocrine insufficiency (S. Gourgiotis, Germanos S. and Ridolfini, M. P., Surgical management of chronic pancreatitis; 2007; 6; 121-133).

The natural effort to reduce the risk of postoperative complications and the implementation of more conservative surgery has led us to develop our own method of treatment of such patients.

The object of the invention is to improve the efficiency of surgical treatment for patients with chronic pancreatitis complicated by formation of pseudocyst head, body and tail of the pancreas, by reducing the morbidity of surgical intervention and the risk of postoperative complications.

The problem is solved by performing a distal resection of the pancreas� cancer, characterized in that the distal resection of the pancreas is carried out by crossing the parenchyma to the right of the superior mesenteric vein, and then carry out a resection of the anterior surface of pseudocyst the head of the pancreas and form pancreaticoduodenectomies with a dedicated loop of the small intestine Roux.

Distal resection of the pancreas, we performed by the standard technique of crossing the body to the right of the superior mesenteric vein. Resecure front surface of cysts in the pancreatic head. Performed instrumental revision of the main pancreatic duct. Then select a loop of the small intestine Roux, disabled Department supplied behind the colon into the stump of the pancreas. Overlay pancreaticoduodenectomies with the walls of the cysts and the anterior surface of the pancreatic head with a continuous suture.

Thus, we have developed a method of treatment of patients with chronic pancreatitis complicated by formation of pseudocyst head, body and tail of the pancreas, allows, on the one hand, to reduce the invasiveness of the surgery but compared with total pancreatectomy, on the other hand, reduces the risk of pancreatic fistula compared with Subtotal pancreatectomy.

The following examples illustrate the method of the invention.

Patient �., For 39 years.

Diagnosis primary: Primary chronic relapsing pancreatitis.

Related disease: diabetes mellitus type 2 in the stage of decompensation.

Complications primary diagnosis: Formation of pancreatic pseudocysts.

From the anamnesis: the first attack of abdominal pain noted in 2004, after errors in diet, the ambulance rushed to hospital in a residence where there was a suspected acute appendicitis. At emergency laparotomy in abdominal cavity revealed a hemorrhagic effusion in pancreas cysts; performed speaktome, the abdominal cavity. If further treatment from another medical institution cyst of the pancreas puncture drained. Since 2008 periodically worried about the pain, since August 2012, the pain was constant. 06.09.2012 was urgently operated, performed diagnostic laparoscopy (alpha amylase effusion abdominal cavity - 8200 u/ml).

Then I entered the fsbi national research centre of surgery RAMS for treatment. When examined by CT abdomen pancreas sharply thickened, markedly heterogeneous structure due to the multiple conglomerate inclusions of high density and drain avascular cysts with a diameter of 5.5 cm, associated with a pancreatic duct. Parapancreatic tissue around the head is sealed with strips�Oh accumbens effusion in hepato-duodenal area and gallbladder bed.

28.11.2012 performed distal pancreatectomy with crossing the parenchyma to the right of the superior mesenteric vein, resection of the anterior surface of cysts in the pancreatic head, pancreaticojejunostomy off on a loop of the small intestine Roux. Verkhnesadinsky laparotomy with excision of postoperative scar. At audit of whole pancreas presents photoelasticity cysts. The largest diameter of the cyst in the pancreas head about 6 cm in the Pancreas is mobilized by top and bottom edges. Made the mobilization of the gland from tail, vascular structures coagulated, stitched or bandaged. Splenic vein tied at 5 mm distal to the superior mesenteric vein. Pancreas crossed to the right of the superior mesenteric vein. Parenchyma and Virunga duct contain concretions removed. Virunga duct at the level crossing about 6 mm. Resected anterior surface pseudocyst of the pancreatic head, traced Virunga duct. Some distance of 40 cm from the ligament of Trace off loop after Roux summed up in reregistration space through the mesentery of the transverse colon and pancreaticoduodenectomies continuous suture.

The postoperative period was uneventful. Control drainage from the area of pancreaticojejunostomy UD�flax on the 3rd day. The patient was discharged in satisfactory condition on the 9th day after the operation. In blood test at discharge: ar. 3,66x10 /l; HB 119 g/l; Ht of 34.5%; a clot. 319x109/l; leukocytes 9,6x109/l, bilirubin Ls. 12.1 µmol/l; protein Ls. 62 g/l, albumin 32 g/l; glucose 8.5 mmol/l; ACT 30 U/l; ALT 50 u/L.

Pain syndrome was arrested.

Our proposed method allows to reduce the volume of operation, save the part of the parenchyma of the pancreas and the physiological passage of food and bile in the gastrointestinal tract. As a consequence, reduced during surgery, eliminating the occurrence of complications such as failure of hepatic and gastronomists, decreases the risk of endo - and exocrine insufficiency, postoperative period runs more smoothly with the early activation of patients. Furthermore, the presence of formed fibrous walls pseudocysts allowed to impose strong pancreaticoduodenectomies with minimal likelihood of insolvency.

The developed method allows us to perform an adequate extent of surgery with minimal invasiveness and low risk of complications compared to traditional methods of treatment.

A positive result allows to expect that the proposed method will find wide application in the treatment of patients with chronic �ancreatitis, complicated by the formation pseudocyst head, body and tail of the pancreas.

Method of surgical treatment of chronic pancreatitis complicated by formation of pseudocyst head, body and tail of the pancreas, comprising a distal resection of the pancreas, characterized in that the distal resection of the pancreas is carried out by crossing the parenchyma to the right of the superior mesenteric vein, and then carry out a resection of the anterior surface of pseudocyst the head of the pancreas and form pancreaticoduodenectomies with a dedicated loop of the small intestine Roux.



 

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