RU2085125C1 - Method for surgical treatment of pyloroduodenal ulcers - Google Patents

Abstract

FIELD: medicine; surgical treatment of digestive organs. SUBSTANCE: proposed method resides in that patient is first subjected to selective proximal vagotomy, followed by resecting pyloric segment of stomach and initial segment of ulcer-affected duodenum. Next circularly separated serous-muscular layer of stomach distal segment is dissected along lesser and greater curvature of stomach. Layer thus-dissected is wound up and fixed, as doubling, to serous membrane of stomach. Finally, anastomosis is applied between distal segment of stomach and duodenum. EFFECT: prevented development of gastritis reflux and dumping syndrome during postoperative period. 9 dwg

Description

 The invention relates to medicine, namely to surgery of the digestive system, and relates to methods for surgical treatment of peptic ulcer.

Known methods for the surgical treatment of pyloroduodenal ulcers by selective proximal vagotomy and its complement, draining the stomach operations [1]
However, these methods do not exclude the development in the postoperative period of recurrence of ulcers, dumping syndrome and reflux gastritis.

Closest to the proposed method for the surgical treatment of pyloroduodenal ulcers (prototype) is a method for the surgical treatment of peptic ulcer of the duodenum by selective proximal vagotomy with resection of the upper horizontal part of the duodenum with an ulcer and subsequent anastomosis between the pyloric stomach and duodenum [2]
At the same time, the application of the known method is possible only with localization of the ulcer in the initial part of the duodenum and does not exclude the possibility of the occurrence of reflux gastritis and dumping syndrome in the postoperative period.

 The purpose of the invention is the prevention of the development in the postoperative period of reflux gastritis and dumping syndrome, the expansion of the scope of use.

 This goal is achieved by the fact that when implementing the method of surgical treatment of sawtooth duodenal ulcers by selective proximal vagotomy with subsequent application of gastroduodenoanastomosis, the pyloric section of the stomach and the initial section of the duodenum with an ulcer are resected, then the circularly separated serous-muscular layer of the distal section of the large and small stomach dissects , wrap and fix in the form of a duplicate to the serous membrane of the stomach.

 New in the proposed invention is that the pyloric stomach and the initial part of the duodenum are resected with an ulcer, then the circularly separated serous-muscular layer of the distal stomach is cut along the small and large curvature, wrapped and fixed in the form of a duplicate to the serous membrane of the stomach, then impose an anastomosis between the distal stomach and the duodenum.

 This method can be successfully used in healthcare.

 Thus, the present invention meets the criteria of "novelty" and "industrial applicability".

 The method is as follows.

 In a patient with an established diagnosis, confirmed radiologically and endoscopically, selective proximal vagotomy is performed.

 They mobilize the distal stomach while preserving the vessels along the lesser and greater curvatures. At the level of the antrum, the right gastric and right gastro-omental gland are crossed and ligated. The initial part of the duodenum from adhesions and adhesions is mobilized.

 After that, the upper border of the resection is outlined above the pyloric pulp and below the duodenal bulb the lower border of the resection (Fig. 1). The sero-muscular membrane is circularly dissected along the resection line with the submucosal vessels stitched, the mucous-submucosal layer is stitched with the UO-40 apparatus, the resected part is removed (Fig. 2 and 3). Using tweezers and a scalpel, the sero-muscular layer of the distal stomach with a width of 10 to 15 mm is circularly separated, dissected by small and large curvature and wrapped (Fig. 4). The resulting two serous-muscle flaps along the front and back surfaces of the stomach are fixed in the form of a duplicate to the serous membrane of the stomach. To do this, the minor serosuscular flap (Fig. 5) is sutured in the front (Fig. 6) by the small curvature of the posterior sero-muscular flap fixed to the serous membrane of the stomach (Fig. 6), and the greater serosuscular flap, fixed to the serous membrane of the stomach, is hemmed by the greater curvature (Fig. 7) hem the back (Fig. 8). Thus, an analogy of pyloric pulp is created.

 The operation ends with the application of an anastomosis between the distal stomach and the duodenum as follows. First, single sero-muscular sutures are placed on the stomach near the distal edge of the sero-muscular duplicate and across the edge of the sero-muscular layer of the duodenum. Next, impose a thin catgut (000) on the atraumatic needle of the submucosal suture of the posterior lip of the anastomosis using the "on-the-fly" method. The front lip of the anastomosis is sutured in a similar way, only in the reverse order (Fig. 9).

 An example of a specific implementation of the method. Patient B., 26 years old, was treated in the 1st surgical department with a diagnosis of duodenal ulcer.

 Upon admission, the patient complained of pain in the epigastric region with radiation to the lumbar region, nausea, heartburn, belching. For the first time, pain in the epigastric region appeared 7 years ago during military service. Repeatedly treated in the gastroenterological department. Received spa treatment. There was a temporary effect.

 Conducted a comprehensive survey. An X-ray and endoscopic examination revealed an ulcer of the posterior wall of the duodenal bulb, cicatricial-ulcerative deformation of the pyloroduodenal zone, duodenogastric reflux, and distal gastritis.

 In a planned manner, an operation was performed - selective proximal vagotomy, pylorobulbectomy, end-to-end gastroduodenoanastomosis. The operation was performed under endotracheal anesthesia. After intubation of the trachea, a probe was installed in the stomach to aspirate the gastric contents.

 The abdominal cavity was opened in layers by the upper-median laparotomic access. During the audit, deformation of the pyloroduodenal zone, the phenomena of pereulbitis and pereduodenitis were found. A selective proximal vagotomy was performed according to the method described by Yu.M. Pantsyrev and A.A. Grinberg, 1979

 The distal stomach and the initial part of the duodenum were mobilized with preservation of the vessels along the lesser and greater curvatures. At the level of the antrum, the right gastric and gastrointestinal artery are ligated and crossed. When mobilizing the initial part of the duodenum from adhesions and adhesions, it was found that the ulcer penetrates into the hepatoduodenal ligament. With the help of a disector, the serous-muscular membrane over the ulcer is separated, cut off and left on the hepatoduodenal ligament. Next, outline the upper boundary of the resection above the pyloric pulp and suture the holder. Below the bulb of the duodenum, the lower boundary of the resection is outlined and the sutures of the holder are applied. The sero-muscular membrane is circularly dissected along the resection line with the submucosal vessels stitched with separate catgut sutures. The mucous-submucous layer is stitched with the UO-40 device. The resected portion is removed. Using tweezers and a scalpel, the serous-muscular layer of the distal stomach is circularly separated from 10 to 15 mm wide. cut through the small and large curvature and wrap. Thus obtained, two serous-muscle flaps along the front and back surfaces of the stomach are fixed in the form of a duplicate to the serous membrane of the stomach. For this purpose, the posterior sero-muscular flap is sutured in the front by a small curvature of the posterior sero-muscular flap fixed to the serous membrane of the stomach, and the posterior sero-muscular flap is fixed in the curvature of the anterior fixed by serous membrane of the stomach. Thus, an analogy of pyloric pulp was created. Excess mucosa of the distal stomach is cut off.

 The operation ends with the imposition of end-to-end gastroduodenoanastomosis. For this, single sero-muscular sutures are placed on the stomach near the distal edge of the sero-muscular duplicate and across the edge of the sero-muscular layer of the duodenum. The submucosal suture is applied using the known oncoming suture technique. With a thin catgut (000) along the small and large curvature, the submucosal layer of the distal stomach and duodenum is sutured with two ligatures. Moreover, the node is located in the middle of the ligature. Suturing of the posterior lip of the anastomosis is performed by a continuous suture in the opposite direction, using the free ends of both catgut ligatures. In the center of the posterior lip of the anastomosis, catgut ligatures are connected, excess suture material is cut off. The front lip of the anastomosis is sutured in a similar way only in the reverse order.

 For enteral nutrition, a microprobe is installed in the jejunum. Seams on a wound in layers. Aseptic sticker.

 The postoperative period was uneventful. On the 10th day, skin sutures were removed. Primary healing. The patient was discharged for outpatient treatment. Control inspection after two months and subsequently every six months. Survey and examination results in a year.

 No complaints. He does not follow a diet. He gained 7 kg in weight. According to x-ray examination, evacuation from the stomach in separate portions. Anastomosis opens up to 1.5 cm and closes completely. In the Trendelenburg position, duodenogastric reflux was not detected. According to fibrogastroduodenoscopy, the anastomosis closes completely, at the time of inspection of bile in the stomach there is no mucous membrane of normal color. According to the results of a histological examination of a biopsy of the mucosa of the antrum and the anastomotic region, no changes were detected. In the gastric juice, bile acids are absent. According to electrogastrography, the normokinetic type.

 The result of a clinical trial of the method of surgical treatment of pyloroduodenal ulcers showed that in the postoperative period the patient fully normalized the motor-evacuation function of the stomach. The newly formed analog of pyloric pulp has the ability to prevent the development of dumping syndrome and reflux gastritis.

 The development of this method was carried out on 10 outbred dogs. In the clinic, 24 patients were operated on using this technique. In the early and distant postoperative period, complications were not observed. The observation period for patients is from one to five years.

 Thus, the proposed method for the surgical treatment of pyloroduodenal ulcers allows you to remove the ulcerative lesion and functionally insolvent or organically altered pyloric pulp, reduce gastric secretion, normalize the motor-evacuation function of the stomach, prevent the development of reflux gastritis, dumping syndrome and relapse of ulcers in the postoperative period.

Bibliography
1. Shaposhnikov A.V., Nedelko A.I. Panteleeva L.A. Vagotomy in the treatment of pyloroduodenal ulcers. Rostov n / a, 1989, 192 p.

 2. Donets N.P. The use of pyloric-preserving operations in combination with selective proximal vagotomy in patients with kalesny, penetrating and stenosing ulcers of the duodenal bulb. Dis. Cand. honey. sciences. Kharkov, 1984.

Claims (1)

 A method of surgical treatment of pyloroduodenal ulcers, including selective proximal vagotomy, resection of the initial part of the duodenum with subsequent application of gastroduodenoanastomosis, characterized in that the resection of the pyloroduodenal zone is performed, placing the lower border of the resection below the duodenal bulb above the upper pyloric ulcer, and the upper - see proximal to it, the sero-muscular layer of the stomach is circularly separated by small and large curvature, wrapped and fixed in the form of they are drawn to the serous membrane of the stomach and then anastomosis is applied between the distal stomach and the duodenum.

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