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I. ДИАГНОСТИКА
PYLORODUODENAL STENTING OF THE TUMORS OF PANCREATOBILIARY ZONE
UDC 616-006.66
Abdrashev Ye.B., Daukenova K.A., Aliev A.K.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty
ABOUT THE AUTHORS
Abdrashev Yerlan Baitureyevich - a high level certificate physician, head of the department of functional diagnostics and endoscopy of the NSCS named after A.N.Syzganov.
Abstract
This article describes the problem of the palliative treatment of patients with incurable malignancies of pancreatoduodenal zone. The experience of treatment of the above-mentioned categories of patients, complicated with obstructive jaundice and duodenal obstruction, is presented. The questions of tactics and minimally invasive endoscopic methods of treatment in this group of heavy patients are raised.
Панкреатобилиарлык аймагындагы iciKTepfli пилородуоденалды стенттшеу
Key words
piloroduodenal stenting, tumor of pancreatobiliary zone, duodenal obstruction, palliative care, minimally invasive intervention, self-expanding stents, endoscopy of the digestive tract.
Эбдрашев Е.Б., Дэукенова К.А., Алиев А.К.
А.Н. Сызранов атындаш Улттык, шлыми хирургиялык, орталыш, Алматы
Ацдатпа
Б±л макалада панкреатодуоденалды аймаеыныц кратер iciri дертше шалдыккан ем конбайтын пациенттердi паллиативт емдеу мэселелер '1 каралады. Сондай- ак, механикалык сары ауру мен ду-оденалды туйнелу'шен аскынеан аурулардыц керсетлген категориясынын, емн журпзу тэжiрибеci сипатталган. Пациенттерд 'щ аталмыштай ауыр тобын емдеуд 'щ аз инвазивты эндоскопиялык эдicтерi мен тактика мэселелер '1 каралмак.
Туйш сездер
пилородуоденалды стенттшеу, панкреатобилиарлык аймашндаш ¡с1к, ултабардыц туйнелуi, паллиативт¡к кемек керсету, минималды инвазивтк араласу, дербес кецейтелн стенл, асказан- 'шек жолдарыныц эндоскопиясы.
Пилородуоденальное стентирование при образованиях панкреатобилиарной зоны
Абдрашев E^., Даукенова К.А., Алиев А.К.
Национальный научный центр хирургии имени А.Н. Сызганова, Алматы
Аннотация
В данной статье рассмотрены вопросы паллиативного лечения инкурабельных пациентов со злокачественными заболеваниями панкреатодуоденальной зоны. Описан опыт ведения вышеуказанной категории больных, осложненных механической желтухой и дуоденальной непроходимостью. Подняты вопросы тактики и малоинвазивных эндоскопических методов лечения у данной тяжёлой группы пациентов.
ОБ АВТОРАХ
Абдрашев Ерлан Байтуреевич -врач высшей категории, заведующий отделением функциональной диагностики и эндоскопии ННЦХ им.А.Н.Сызганова. E-mail: yerlanabdrashev@gmail.com.
Ключевые слова
пилородуоденальное стентиро-вание, опухоль панкреатобили-арной зоны, непроходимость двенадцатиперстной кишки, паллиативная помощь, минимально инвазивное вмешательство, самостоятельно расширяющий стент, эндоскопия желудочно-кишечного тракта.
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Actuality:
The problem of timely diagnosis of different types of tumors remains a major problem in modern oncology. Still sick, in most cases, seek specialized medical care only in the later stages of the disease. In this regard, the development and introduction into everyday practice of highly efficient and minimally invasive methods of treatment tumor strictures is relevant. Last years abroad various methods of stenting of hollow organs were widely used. At the same time, in our country, this method is only used in some hospitals.
Objective:
The study of stenting as palliative and final method of treatment to restore patency with stenosis hepatopancreatobiliary and duodenal area of tumor genesis. As well as improving the quality of life of cancer patients remaining in the inoperable cases, refusal of surgery or severe comorbidity.
Literary Reference:
For the first time metallic self-expanding stents were used in 1985, when Wright et al. successfully implanted stents in the occluded jugular vein and the abdominal aorta of a dog. Currently stenting has become widespread and is used in various surgical diseases caused by the obstruction of blood
Figure 1.
Change of pylorus by neoplastic process.
Figure 2.
Tumoral stenosis of pyloric channel.
Figure 3.
Stenting step.
Figure 4.
Stent after installation
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vessels, the urethra, trachea, esophagus, biliary tree and a number of other anatomical structures.
Material and Methods:
In the endoscopy department of the National Scientific Center of Surgery named after A.N. Syz-ganov there were held 4 piloroduodenal stenting. Self-expanding set of partially coated and uncoat-ed stents manufactured by «MI Tech», South Korea. Uncoated stents are installed in cases where an additional stenting was performed with endo-biliary nitinol self-expanding stents in an "end-toside." Other patients have partial-coated stents. Two patients with cancer of pancreatobiliary duodenal area, complicated by obstruction of the bile duct and duodenum, were performed a combined endoscopic biliary pyloroduodenal stenting. The most common complication of malignant tumors of pancreatobiliary area is the development of jaundice. One of the physiological methods of biliary decompression in this case is the stenting of the bile duct. In some patients the disease is subsequently complicated by the formation of duodenal stenosis (Figure 1,2).
It worsens the already grave condition of the patient. Duodenal obstruction complicates and is often an obstacle to the implementation of trans-papillary biliary endoprosthesis or change occluded
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stent. The solution to this problem is to install pylo-roduodenal self-expanding stents (Figure 3,4).
Thus it is possible to avoid an execution of traumatic surgery. All patients - two women aged 70 to 77 years and two men from 67 to 74 years. In four cases, tumor is localized in the head of the pancreas; in 1 case there was a tumor of major duodenal papilla (in the anamnesis cholecystectomy for six months before the onset of jaundice). Two patients at the first admission to hospital with obstructive jaundice had no signs of stenosis of the duodenum, and it was performed only transpapillary biliary stenting in one case setting self-expanding covered stent in the other - a plastic stent Soehendra-Tan-nenbaum (Wilson-Cook) diameter of 8.5 Fr. Symptoms of duodenal obstruction occurred in these patients after 3.5 and 6 months, respectively: the first patient was set pyloroduodenal stent, the second - was performed of plastic biliary stent changed on simultaneous implantation of self-expanding pyloroduodenal stent. Two other patients had a combination of obstructive jaundice and duodenal stenosis with the localization of the tumor stricture at the level of the duodenal bulb. In all cases, the HANAROSTENT (MITech, South Korea) stents were used. From 3 biliary stents were coated with 1 - uncovered. Pyloroduodenal endoprosthesis was performed in 3 patients with uncoated stents; in one case at a time set two endoprosthesis - first uncovered, then covered with a "stent-in-stent".
Results:
Stent implantation was successful in all cases, the phenomenon of jaundice has been cropped, enteral nutrition is restored. Complications were not recorded. All patients were discharged from the hospital. In the distant period signs of recurrence of obstructive jaundice or duodenal obstruction were noted (Figure 5, 6).
Figure 5.
Two weeks after stenting.
Figure 6.
Two weeks after stenting. Duodenum
Conclusions:
Our experience allows us to conclude that the use of self-expanding stents in malignant tumors of pancreatobiliary area, complicated by biliary and duodenal obstruction, can effectively restore outflow of bile and duodenal patency and can be recommended as a definitive palliative treatment in this severe category of patients.
References
1. Erika Madrigal, Jennifer Chennat. Endoscopic management of pancreatic cancer: from diagnosis to palliative therapy. Pancreatic cancer - clinical management. March, 2012, p. 213-236.
2. Matthew L. Silviera , Mark J. Seamon, Brian Porshin-sky, Mark P. Prosciak, Vijay A. Doraiswamy, Cecilia F. Wang, Manuel Lorenzo, Michael Truitt, John Biboa, Amy M. Jarvis, Vimal K. Narula, Steven M. Steinberg, S. Peter Stawick. Complications related to endoscop-ic retrograde cholangiopancreatography: A comprehensive clinical review. p. 73-82.
3. Mittal A., Windsor J., Woodfield J., Casey P., Lane M. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Brit-
ish Journal of Surgery. Volume 91, Issue 2, pages 205-209, February 2004.
4. Ivo Bokoski, Andrea Tringali, Pietro Familiari, Massi-miliano Mutignani, Guido Costamagna. Self-expandable metallic stents for malignant gastric outlet obstruction. Advances in therapy. October 2010, Volume 27, Issue 10, pp 691-703.
5. Sasaki T., Isayama H., Maetani I., Nakai Y., Kogure H., Kawakubo K., Mizuno S., Yagioka H., Matsubara S., Ito Y., Yamamoto N., Sasahira N., Hirano K., Tsujino T.,Toda N., Tada M., Koike K. Japanese multicenter estimation of WallFlex duodenal stent for unresectable malignant gastric outletobstruction. Digestive Endoscopy. Volume 25, Issue 1, pages 1-6, January 2013
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