PANCREATODUODENECTOMY

From Big Medical Encyclopedia

PANCREATODUODENECTOMY (Greek pankreas, pankreatos pancreas + lat. duodenum a duodenum + grech, ektome excision, removal) — operation of full or partial removal of a pancreas together with a duodenum.

Distinguish total P. (the pancreas is deleted completely) and a pankreatoduodenalny resection, or partial P. (a part of a pancreas is kept).

The Pankreatoduodenalny resection is carried out most often. More than 100 techniques of a pankreatoduodenalny resection differing on a way of processing of a stump of a pancreas, methods of imposing of an anastomosis and an order of anastamosing of a stump of a pancreas, bilious ways and stumps of a stomach with a jejunum are offered. Most often apply Chayld's technique in various modifications.

Sewing up of a stump of a pancreas tightly can lead to development of a pancreatonecrosis or persistent pancreatic fistula in the postoperative period, switching off of a pancreas nz digestion — to disturbances of digestion and absorption of food. Therefore sewing up of a stump of a pancreas is applied tightly seldom, generally at chronic indurative pancreatitis with sharp disturbance of vneshnesekretorny function or when there is only her tail.

The technique of a pankreatoduodenalny resection with the sequential arrangement on a loop of a jejunum of a pankreato-eyunalny, gepatiko-eyunalny and gastrojejunal anastomosis is most reasonable.

Indications to performance of a pankreatoduodenalny resection in a planned order: malignant new growths of a head of a pancreas, big nipple of a duodenum, distal department of the general bilious channel, duodenum; hron, pancreatitis with rough indurative changes in the field of a head at minor changes in a body and tail of a pancreas; hormonal and active benign tumors of a pancreas at their deep arrangement in the field of a head or an ankyroid shoot of gland. The Pankreatoduodenalny resection can be executed as one of stages of the combined operative measure concerning malignant tumors of other bodies with germination in a pancreas in the absence of the remote metastasises.

According to urgent indications the pankreatoduodenalny resection is carried out at injuries of a stomach with crush of a head of a pancreas and duodenum.

Total P. is made very seldom. Generally it is shown at malignant tumors with damage of all pancreas. Sometimes it is carried out at the total pancreatonecrosis complicated by a necrosis of a duodenum and also at chronic indurative painful pancreatitis.

Contraindications to a pankreatoduodenalny resection: old age, serious condition, existence of cardiovascular, respiratory, hepatonephric insufficiency. A relative contraindication is germination of a tumor in verkhnebryzheechny vessels, the general hepatic artery, the lower vena cava, but at patients of young age at a satisfactory general condition the pankreatoduodenalny resection with excision of the vessels affected with a tumor and their subsequent plastics is shown.

In the preoperative period correction of water and electrolytic balance, Disintoxication therapy, fortifying treatment is necessary.

Fig. 1. Diagrammatic representation of stages of mobilization of a duodenum and head of a pancreas: and — mobilization of a duodenum on Kokhera by a section of the leaf of a parietal peritoneum (1) covering vertical department of a gut (2); — the duodenum (1) is removed medially, naked a head (2) pancreases; in — a duodenum (1) and a head (2) pancreases are mobilized and displaced medially, naked retroduodenal department of the general bilious channel (3) and the lower vena cava (4).
Fig. 2. The scheme of carrying out manual audit for definition of a possibility of mobilization of an isthmus of a pancreas (1) over a portal vein: the stomach (2) after a section of a gastrolic sheaf (3) is delayed up.

Operation is carried out under an intubation anesthesia. Operational access — upper median or cross laparotomy (see). Make the general survey of abdominal organs for definition of operability; survey and a palpation of a root of a mesentery where quite often the tumor sprouts a mesentery; survey of a front surface of a pancreas after a section of a gastrolic sheaf. The nature of relationship of a tumor and the lower vena cava define after broad mobilization of a head of a pancreas and a duodenum on Kokhera (fig. 1), and relationship of a tumor with mesenteric vessels — after mobilization of an isthmus of a pancreas over a portal vein (fig. 2).

Fig. 3. The scheme of removal of a complex of bodies at a pankreatoduodenalny resection: the stomach (1) (the deleted part it is taken away to the right), the general bilious channel (2), a body of a pancreas (3), a jejunum are crossed (4).
Fig. 4. The diagrammatic representation of crossing of the short vessels (1) going to a head (2) pancreases which deleted part is taken away lateralno.

In case of operability of a tumor will mobilize and delete pankreatoduodenalny organokompleks in the following borders (fig. 3): a stomach cross it at the level of 1/2, tie up and cross the right gastric artery, make cholecystectomia (see), cross and will mobilize the general bilious channel together with people around limf, nodes (at tumoral defeat — the general hepatic channel is higher than the place of a confluence of a vesical channel). Tie up and cross a gastroduodenal artery. Limf, nodes on the course of the general hepatic artery displace towards a pancreas. Cross a jejunum below a duode-noyeyunalny sheaf (Trentts's team). Stitch and cross the short vessels connecting a head and an ankyroid shoot of a pancreas with verkhnebryzheechny vessels (fig. 4).

Fig. 5. Diagrammatic representation of stages of carrying out pankreatoyeyunoanastomoz: and — sewing together of a virzungov of a channel (1) with a gleam of a small bowel (2); — sewing together of a parenchyma of gland (1) with a wall (2) of a small bowel; in — suture (1), invaginating the line of a pankreatoyeyunalny anastomosis (2) in a gleam of a gut; — the invaginating seams (1) are tied, imposing of additional seams (2) on a pancreas and a wall of a small bowel.
Fig. 6. Diagrammatic representation of a gepatikoyeyunoanastomoz: and — a podshivaniye of the general hepatic channel (1) to a serous cover of a small bowel (2) noose sutures; — suture (1), invaginating finished gepatikoyeyunoanastomoz (2) in a gleam of a small bowel (3); in — the invaginating seams (1) are tied, imposing of additional seams (2) on a wall of the general hepatic channel (3) and a small bowel (4).
Fig. 7. The diagrammatic representation of a final stage of a pankreatoduodenalny resection after imposing pankreatoyeyunalny (1), gepatikoyeyunalny (2) and a gastroenteroanastomosis (3).

The recovery stage of operation consists of the next moments. Pankreatoyeyunoanastomoz impose the end in the end or the end sideways. For the best sealing the pancreat duct (virzung a channel) is sewed in a gleam of a gut, and the line of an anastomosis invaginate (fig. 5). Otstupya 15 — 20 cm from a pankreatoyeyunoanastomoz, impose holedokhoyeyuno-or gepatikoyeyunoanastomoz the end sideways, immersing the line it pleated walls of a gut (fig. 6). The last stage is the anastomosis of a stump of a stomach with a jejunum the end sideways at distance of 30 — 35 cm from a gepatikoyeyunoanastomoz (fig. 7). Rational action is drainage of the bringing loop the transnasal probe which is carried out to a pankreatoyeyunalny anastomosis. It allows to evacuate bile and pancreatic juice in the first 2 — 4 days after operation. Through separate abdominal sections in the right and left podreberye bring drainages to gepatiko-and to a pankreatoyeyuioanastomoz.

At germination of a tumor in a portal vein after crossing of an isthmus of a pancreas it is necessary to isolate an affected area of a vein imposing of tourniquets on upper mesenteric, splenic and portal veins and to excise a tumor together with the site of a vein. Defect in a wall of a vein is taken in a side seam. In case of disturbance at the same time of a blood flow on a vessel it is tsirkulyarno necessary to excise the site of a vein and to impose a vascular anastomosis. If diameter of the general hepatic channel less than 1 cm, it longwise is cut on 1 — 2,0 cm that diameter of a gepatikoyeyunoanastomoz was not less than 2 cm.

In the postoperative period full and timely correction of proteinaceous losses and water and electrolytic balance, holding actions for prevention of acute pancreatitis and hepatonephric insufficiency, control and correction of a sugar content in blood are necessary.

After operation recommend the active mode (a rising for the 2nd days), allow to drink and eat food on 2 — the 3rd days.

The purest complications pankreatoduodenalny resection acute pancreatitis of the rest of gland is (see. Pancreatitis ), bilious fistulas (see) and pancreatic fistula (see. Pancreas ). For prevention of postoperative pancreatitis enter cytostatics (5-ftoruratsit), inhibitors of enzymes. Write out from a hospital in the absence of complications on 12 — the 14th days after operation.

The Pankreatoduodenalny resection and in particular total P. can lead to disturbance of digestion and absorption of food, emergence of a diabetes mellitus. At disturbance of digestion and absorption of food recommend protein-rich, with restriction of fats food of 4 — 6 times a day with the small portions. Appoint the drugs compensating digestive activity of pancreatic juice (Pancreatinum, panzinorm), increasing activity of intestinal digestion (Mexasum). Treatment of a diabetes mellitus is carried out according to usual schemes (see. diabetes mellitus ).

In the absence of a recurrence of a basic disease, the good digesting and soaking-up functions of intestines patients in 6 — 12 months after a pankreatoduodenalny resection can do easy manual work.

The lethality after a pankreatoduodenalny resection concerning tumors of a pankreatoduodenalny zone makes 10 — 20%, after operations for an injury of a pancreas — 26 — 45%. The good and satisfactory long-term results of a pankreatoduodenalny resection apropos hron, pancreatitis make 70 — 90%.

Survival within 5 years and more after a pankreatoduodenalny resection concerning a pancreatic cancer is observed in 7 — 12%, cancer of a big nipple of a duodenum — 25 — 30%, cancer of distal department of the general bilious channel — 20 — 25% of cases.

See also Duodenectomy .


Bibliography: Shalimov A. A. Diseases of a pancreas and their surgical treatment, M., 1970; Shalimov A. A., Radzikhovsky A. P. and Semi-pas of ii B. N. Atlas of operations on a liver, bilious ways, pancreas and intestines, page 184, M., 1979; Hess W. Die chronische Pankreatitis, Bern, 1969; Howard J. Jordan G. L. Surgical disease of the pancreas, Philadelphia — Montreal, 1960.


A. A. Shalimov.

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