RU2012238C1 - Method of treating perforating and hemorrhagic duodenal ulcer - Google Patents

Abstract

FIELD: medicine, particularly, surgery. SUBSTANCE: essence of invention resided in that duodenum-to-intestinum tenue transition was incised at level of twelfth thoracic vertebra after vagotomy, dissection of ulcer and hemostasia. Vascular-nervous fascicle was preserved and mobilized together with intestine corner, ascending portion was isolated retroperitoneally and set level. Distal end was positioned intraperitoneally to avoid trauma and prevent relapses in case of U-shape anomaly owing to exclusion of resection and normalization of topography. EFFECT: prevention of relapses and traumas. 2 dwg

Description

 A method of treating perforated and bleeding ulcers of the duodenum relates to medicine, namely to anomalous surgery, and can be used in the treatment of peptic ulcer of the duodenum 12, both complicated by perforation and bleeding, and other complications of peptic ulcer, combined with duodenastasis caused by abnormal v-shaped duodenum.

 In case of duodenal ulcer, one of the main reasons for the development of postoperative complications is duodenostasis that is not eliminated during the operation. The question of the need for correction of duodenostasis in case of duodenal ulcer is beyond doubt.

 The proposed method of treatment is intended for those cases when there is no horizontal part of the duodenum 12, and the descending at an acute angle passes directly into the ascending part.

 The method is illustrated in FIG. 1 and 2.

 The essence of this anomaly is illustrated by the scheme (see Fig. 1), which shows the general view of the duodenum anomalies: 1 - the descending part, 2 - the ascending part, 3 - the lower bend, 4 - the twelve duodenum lean bend, 5 - neurovascular elements of the Treitz ligament, 6 - the intersection of the suspension muscle.

 This anatomical version has been known for a long time. It was first differentiated only in the pathogenesis system of duodenostases of various etiologies and isolated from the system of ineffective methods of surgical treatment.

 Known methods of treating this type of duodenostasis. They bring down the entire descending part of the duodenum (Strong's operation). Significant disadvantages of this method is that it damages the neurovascular apparatus of the medial surface of the intestine, resulting in increased existing duodenostasis. A positive effect is achieved only in 30% of cases.

 In recent years, a modification of this method has been described, characterized in that the operation is supplemented by longitudinal myotomy of the entire ascending part of the intestine. A significant drawback of the modification was that myotomy interferes with the contractile function of the intestine, which led to the development of a new mechanism of duodenostasis.

 A known method of treating duodenostasis by applying an anastomosis between the initial part of the jejunum and the lateral side of the ascending part of the duodenum.

 The disadvantage of this method is the high percentage (34%) of complications in the form of anastomosites.

 The method has significant disadvantages. It is traumatic, since in the retroperitoneal space it resects the duodenojejunal segment, anastomosis is applied, a tunnel is formed between the superior mesenteric artery and the aorta. The method is performed with various forms of duodenostasis, including the U-shape.

 The aim of the invention is to reduce the invasiveness of the operation and the prevention of relapse with its U-shaped anomaly duodenum. The essence of the method lies in the fact that in addition to vagisection and corrective surgical interventions on the pylorubulbar area of the duodenum 12, the peritoneal ring is removed from the 12 duodenum at the site of transition of the parietal leaf to the visceral, mobilize the duodenojejunal bend by partial dissection of the X-ray ligament at the X of the thoracic vertebra due to the extraperitoneal intersection of the suspension muscle while maintaining the neurovascular bundle, this bundle and duodenojejunal bend are mobilized, retroperitoneal secretions are recovered the walking part, give it a horizontal position, and the distal end is placed intraperitoneally.

 In FIG. 2 is a diagram of an operation for a y-shaped anomaly.

 A 29-year-old patient came from the therapeutic department to clarify the diagnosis, where she was diagnosed with peptic ulcer of the duodenum, exacerbation.

 From the anamnesis: for a long time suffers from pain in the right half of the abdomen with irradiation in the back. The attacks were accompanied by nausea, vomiting did not bring relief. The pains were debilitating, lasting several hours. The appetite is sharply reduced. Repeatedly treated for gastritis and spastic colitis, peptic ulcer of the duodenum. As a result of treatment, a temporary effect was noted. An hour before entering the surgical department, sudden severe pains appeared throughout the abdomen. Condition upon receipt of moderate severity.

 Clinical diagnosis: duodenal ulcer complicated by perforation. After preliminary preparation, an urgent operation was performed. On the front surface of the pylorus is a perforated ulcer, the stomach is enlarged, the lesser curvature is at the level of the navel. The horizontal part of the duodenum is absent, the descending part is inflated, reaches the right iliac region and passes immediately to the ascending part. In the region of the Treytz ligament, the duodenojejunal transition occurs at an acute angle.

Operational diagnosis:
U-shaped anomaly of the duodenum, duodenostasis, duodenal ulcer, complicated by perforation, diffuse peritonitis.

 Perforated ulcer, pyloroplasty according to Fenney, trunk vagotomy and removal of duodenostasis by the proposed method were excised.

 A finger was inserted under the mesocolon at the Treytze ligament into the duodenojejunal fossa of the ligament. A peritoneum was mobilized along it from the lateral side of the duodenojejunal bend at the site of transition of the peritoneum from the parietal leaf to the visceral. The peritoneal ring was dissected from the duodenal fossa to the wall of the intestine and around it. On the back surface, starting from the duodenojejunal bend, passing between the duodenum and the spine, a ligament hanging the duodenum was isolated. The intersection of the muscles was made high at the level of the XII thoracic vertebra in the transverse direction, including all fibers, but excluding the adjacent nerves and vessels.

 Then the lateral wall of the duodenum was subsequently mobilized to the previously existing transition of the descending part to the ascending - lower bend. Having created a pocket in the retroperitoneal space, they stupidly walked around the place of transition of the descending part to the ascending one, up to the inner surface of the duodenum, which subsequently serves as the mesentery. At the end of the mobilization, part of the duodenum was rotated clockwise to the left of the spinal column together with all neurovascular connections. At the same time, in the right mesenteric sinus there was an increase in the lower duodenal bend with the transformation of it and the adjacent mobilized part into the horizontal part of the duodenum. The distal segment of the intestine was intraperitoneally displaced.

 As a result of the correction of the duodenum, the entire ascending part of it was in the abdominal cavity and was held by the neurovascular elements, the mobilized part of the duodenum, its horizontal part was reduced. The postoperative period was uneventful. During the control X-ray endoscopic examination after three months: there is no relapse of the ulcer, bile reflux is not detected, there is superficial gastritis, the horizontal branch of the duodenum is clearly defined. When monitoring after 6 months, there are no complaints, with endoscopic examination of gastritis ulcers, there is a timely evacuation from the stomach.

Claims (1)

 METHOD FOR TREATING A PERFORATIVE AND BLOODY BLADDER ULCER, including vagotomy, ulcer excision and stopping bleeding, characterized in that, in order to reduce the morbidity and prevent recurrence in the U-shaped anomaly of duodenal ulcer and excision of the thoracic ulcer, the level of the 12th thoracic vertebra with preservation of the neurovascular bundle, mobilize it and the angle of the intestine, retroperitoneally separate the ascending part, give it a horizontal position, and the distal end is placed intrameritoneally.

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