RU2085126C1 - Method for suturing duodenum stump at complicated forms of peptic ulcer disease - Google Patents

Abstract

FIELD: medicine; surgery; operative treatment of duodenum ulcer. SUBSTANCE: duodenum stump is dissected in longitudinal direction to form anterior and posterior grafts. Posterior graft affected with ulcer is excised, followed by marginal demucosation and by tailoring semioval anterior graft, length of which is equal to 1.0-1.5 diameter of stump. Stump is sutured with purse-string suture at distance 0.5 cm from margin. Anterior graft is turned inside out into duodenum lumen using blanket suture. Finally, ulcer bottom is tamponed by applying second row of П-shaped serous-muscular sutures onto anterior wall of duodenum and onto pancreas capsule. EFFECT: reduced percentage rate of intra- and post- operative complications caused by duodenum stump, extrahepatic system of ducts and pancreas; simpler and faster stump treatment. 6 dwg

Description

 The method relates to medicine, namely to surgery, and can be used in surgical treatment of peptic ulcer of the stomach and duodenum.

 Stomach resection according to the Billroth-II method, and sometimes according to the Billroth-I method (with the application of termolateral gastroenteronastomosis) suggests the need to suture the duodenal stump.

 Great difficulties are encountered if it is necessary to suture the stump with large and giant duodenal ulcers, their penetration and low location, the need to suture the bowel stump with a close location of the BJC or Wirsung duct. After suturing the stump of the duodenum in 0.5% of cases, stump insolvency occurs, and with the indicated complications of peptic ulcer, the incidence of insolvency rises to 4-6 %.In addition, when suturing post-bulbar ulcers, sometimes there are disturbances in the patency of BDSC, and acute pancreatitis also develops. The development in the postoperative period of these complications is accompanied by high mortality and is largely associated with the method of surgical intervention, a method of suturing the stump of the duodenum.

 In the known method of suturing the stump of the duodenum, the principle of radicalism with respect to ulcers is used, which is contained in the Nissen method (1933). Monograph "Surgery of the digestive tract", A. A. Shalimov, V. F. Saenko. Kiev, "Health", 1977. The Nissen method consists in mobilizing the initial section of the intestine and crossing it at the level of the distal edge of the ulcer. The stump is sutured with two rows of nodal sutures. Suture the anterior wall of the stump to the distal edge of the ulcer. The second row of sero-muscular sutures the front wall of the stump is sutured to the proximal edge of the ulcer with the capture of the pancreatic capsule. However, this method does not allow a good revision of the stump and BSDP, nodal sutures overlapping scarred, inflamed edges of the ulcer do not provide a sufficient degree of their reliability with respect to the tightness of the stump, the corners of the stump are its weak points, especially when applying the second row of sutures.

The prototype is the method of suturing the stump of the duodenum according to the method of A. I. Gorbashko. [one]
After longitudinal dissection of the stump of the duodenum to its distal edge, the ulcer is revised and the posterior stump flap is excised. The stump is sutured with two rows of interrupted sutures using the front flap.

 A positive aspect is the provision of the possibility of an initial good visual and palpation revision of the stump, ulcer and BSC, the possibility of more convenient removal of the flap of the posterior intestinal wall. The disadvantage is that the first and second row of nodal sutures are superimposed on the changed tissue in the distal and proximal edges of the ulcer. The corners of the stump are weak points, since difficulties arise in their peritonization. An attempt to provide sufficient mechanical strength of the nodal sutures by deeper stitching of tissues on the pancreas leads to acute pancreatitis, and sometimes stitching or narrowing of the common bile duct or Wirsung duct.

 The objective of the invention is to reduce the likelihood of complications, simplifying and improving the reliability of suturing the stump of the duodenum. The objective of the invention is achieved by the fact that in the proposed method, after cutting the duodenum from the stomach, a longitudinal section of the intestinal stump is made into the front and back flaps. Stump mobilization is carried out to the distal edge of the ulcer, much faster than usual, since it is carried out under visual, palpation, and, if necessary, instrumental control of the ulcer and BSDC. The back flap is excised along with the ulcer. The bottom of the ulcer is sanitized. The front flap is given a semi-oval shape. Suturing of the stump of the duodenum, with large and giant penetrating ulcers, is carried out by applying a purse string suture to the stump, capturing the posterior wall of the intestine distal to the ulcer and screwing, twisting the suture to the front flap. After tightening the pouch, the diameter of the sutured stump decreases, a large degree of anatomical adaptation of the stitched tissues is provided, and the ulcer niche is partially plugged. The second row of mattress serous-intestinal sutures on the front wall of the intestine and the capsule of the pancreas, proximal to the ulcer niche, complete the closure of the ulcer niche.

 Comparative analysis with prototypes allows us to recognize that this technical solution meets the criterion of "novelty."

 When comparing the claimed solution, not only with prototypes, but also with other technical solutions, no solution was found to have similar characteristics, which allows us to conclude that this technical solution meets the criterion of "significant differences".

 In FIG. 1 shows the stump of the duodenum after its longitudinal dissection to the level of the distal edge of the ulcer. Dissection is carried out with an electric knife. On the front wall of the stump, holders are superimposed; in FIG. 2 type of duodenal stump after excision of the posterior wall flap, together with an ulcer penetrating into the pancreas and excision of 5 mm of the mucosa of the posterior semicircle of the intestine; in FIG. 3 view of the stump of the duodenum after the formation of a flap of its anterior wall of the semi-oval shape, from 1 to 1.5 diameters of the intestine; in FIG. 4 first stage of the purse string suture. The posterior semicircle of the stump is stitched at a distance of 5 mm from the edge of the intestine in FIG. 5 final stage of the purse string suture. With a ligature, with which the posterior wall of the intestine is stitched, the front flap is stitched from the inside out by an entwining screwing seam. The beginning and end of the ligature bind. The purse string suture is tightened, while the ulcer niche is partially plugged; in FIG. 6 the imposition of a second row of sutures that completes the tamponade of the ulcer niche. Mattress sutures are applied - serous-muscular on the front wall of the intestine and on the capsule of the pancreas.

The method is as follows:
The duodenum is cut off from the stomach, after its mobilization in a known manner.

 A longitudinal section of the intestinal stump is made between its anterior and posterior wall to the level of the distal edge of the ulcer. To reduce bleeding, an incision is made with an electric knife. Stump mobilization is also performed to the distal edge of the ulcer. In this method, the mobilization is performed faster than usual, since it is carried out under visual, palpation, and, if necessary, instrumental control of the ulcer and BSDC.

 The posterior flap is excised with the ulcer below its distal edge. In the remaining part of the back wall by 5 mm, demucosis is carried out using an electric knife.

 Then a semi-oval flap is cut out from the front wall of the stump with an electric knife. Its length is 1-1.5 of the diameter of the intestine. A thorough hemostasis is performed in the duodenal stump. Sanitize the bottom of the penetrating ulcer.

 Suturing of the duodenal stump begins with suturing its posterior semicircle with a purse string suture, 5 mm from the edge of the stump. For convenience, they sew from the far edge to the front, then the far end of the ligature is charged into the needle holder for flashing the front flap. The flap of the anterior wall of the stump is stitched from the mucosa to serosa and then around the edge of the flap they go to the next suture. Sewing, in this way, the entire flap with a twisted seam and simultaneously tightening each stitch of the seam, the flap is screwed into the intestinal lumen.

 After the back wall of the intestine and the front flap were stitched with a ligature, the purse string suture is tightened at the beginning and end of the ligature. After tying the suture, the stump is reliably sealed and partially tampons the bottom of the ulcer niche remaining on the pancreas.

 By applying the second row of U-shaped serous-muscular sutures to the anterior wall of the duodenal stump and the pancreatic capsule at the proximal edge of the ulcer bottom, the tamponade of the ulcer niche of the anterior stump wall is completed.

An example of a specific implementation:
Patient M., 45 years old, medical history N 383.

 Diagnosis: peptic ulcer of the duodenum, postbulbar duodenal ulcer, penetrating into the head of the pancreas. Condition after suturing perforated gastric ulcer in 1991

 Operation 04/07/93

 Endotracheal narcosis with the use of muscle relaxants and neuroleptanalgesia. Upper middle laparotomy with excision of the old laparotomy scar. In the abdominal cavity, a pronounced adhesion process in the antrum and subhepatic space. After the adhesions were separated, the stomach was found to be of normal size, and in the postbulbar part of the duodenum, an ulcerative infiltrate and an ulcer crater with a diameter of up to 2 cm were found on the upper posterior wall. The stuffing bag was sealed with adhesions. The stomach was mobilized by large and small curvature in a volume of 2/3 with ligation of the right gastro-omental, right and left gastric arteries. The stomach is cut off from the duodenum below the pylorus. On the front wall of the duodenal bulb two ligatures-holders are superimposed. An electric knife is longitudinally dissected in the stump of the duodenum below the distal edge of the ulcer into the anterior and posterior flaps. An ulcer measuring 2.0 x 0.7 x 0.5 cm. An excision of the posterior flap below the distal edge of the ulcer was performed. The bottom of the ulcer remained on the pancreas. Produced curettage and sanitation of the bottom of the ulcer. An electric knife is cut out of the front flap of a semi-oval shape. Demucozation along the edge of the posterior semicircle of the intestine. Quality control of hemostasis. A twisting purse-string purse-string suture was imposed on the stump of the duodenum. Separate kapron U-shaped sutures are sewn on the front wall of the intestine to the capsule of the pancreas. Peritonization of a stump an omentum. Resection of 2/3 of the stomach was performed. Imposed gastroenteroanastomosis according to Billroth-II in the modification of Hoffmeister-Finsterre. The stump of the stomach is sewn into the window of the mesentery of the colon. The abdominal cavity is drained according to Spassokukotsky in the region of the right hypochondrium and is sutured in layers. There were no complications in the near and distant postoperative period.

 This technique of revision and suturing of the stump of the duodenum was also used in patient A., 67 years old, medical history N 23694.

 Diagnosis: peptic ulcer of the duodenum, postbulbar duodenal ulcer, complicated by intestinal bleeding of the II degree, cicatricial deformity of the bulb, acute fatty pancreatitis, cyst of the left ovary. IHD: angina pectoris, II functional class, H I.

 12/20/93, under endotracheal anesthesia with the use of muscle relaxants and neuroleptanalgesia, a resection of 2/3 of the stomach was performed according to Billroth-II in the modification of Balfour with entero-enteroanastomosis according to Brown, the stump of the duodenum was processed according to the proposed method. The cysts of the right ovary and the right fallopian tube were removed. The abdominal cavity is drained in the right hypochondrium according to Spassokukotsky and sutured. No complications were observed in the near and distant postoperative period.

 Thus, the method allows to increase the degree of prevention of complications during and after surgery (stump dissection and primary visual, palpation or instrumental control of the stump, ulcer, BSC), provides a greater degree of mechanical and in respect of microflora hermetic stump (due to the imposition of purse-string screw suture), provides anatomical adaptation of stitched tissues, less traumatic (they do not emit the posterior semicircle of the intestine), easy to perform, suturing time is reduced, there is less suture material, better trophic tissue of the stump and pancreas, a closed cavity is not formed between the rows of sutures in the duodenal stump, as is the case with some methods of applying a purse string suture with other methods of suturing the stump.

Claims (1)

 A method of suturing a duodenal stump during surgical treatment of a post-bulbous ulcer penetrating into the pancreas, including longitudinal dissection of the stump into the anterior and posterior flaps distal to the ulcer, radical removal of the ulcer, characterized in that a semi-oval anterior flap 1.0 1.5 1.5 times the stump diameter is formed, excision of the posterior flap, marginal demucosis of the posterior intestinal semicircle and stitching it at a distance of 0.5 cm from the edge with a purse string suture, continue it to the front flap in the form of a twisting screw the suture and tighten, sealing the intestine and partially tamponing the bottom of the wound, after which a second row of U-shaped serous-muscular sutures is applied to the anterior wall and capsule of the pancreas, completing the tamponade of the bottom of the ulcer.

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