RU2121306C1 - Surgical method for treating lesser curvature stomach ulcers - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out selective proximal vagotomy along stomach lesser curvature outside of lesser curvature infiltration zone. Angular subtotal medial stomach body resection is carried out, innervated and oral regions being retained. Ulcer crater on the lesser curvature is left. Cardia areflux property is repaired by creating invagination esophagocardiofundal valve. Two chambered stomach is created. Invagination tubular corporoantral areflux anastomosis is applied. EFFECT: reduced number of recidivation cases. 8 dwg

Description

 The invention relates to medicine, namely to surgery and can be used to treat gastric ulcer.

 A gastric ulcer is characterized by resistance to conservative therapy and a high tendency to malignancy - 12 - 14% (Nechay A.I. et al., 1987, Britvin A.A. et al., 1984), which dictates the need to widely give indications for surgical treatment this pathology.

 The classic "operation of choice" to date is the resection of the stomach according to the method of Billroth-1 or Billroth-2. However, at the same time, the most important section of the gastrointestinal tract, the antrum and the pyloric sphincter, from the functional and trophic points of view, is irretrievably lost. As a result, after such operations, severe functional disorders develop - 15-30% or more (Vilyavin G.F. et al., 1975), in 10-15% of cases post-gastroresection syndromes develop (Vasilenko V.Kh. et al., 1974 Kuzin M.I., 1978).

 Recently, the so-called organ-preserving and organ-sparing operations have been increasingly developed and put into practice. Among them is stem or selective gastric vagotomy with pyloroplasty or antrumectomy. However, these operations, while preserving the stomach, completely denervate it and destroy the pylorus, as a result of which postvagotomy syndromes develop in 5-22% (Kuzin N.M. et al., 1986), which eliminates the “functional” result of these interventions. In addition, there remains the possibility of relapse of the ulcer - in 4.6% (Kuzin N.M. et al., 1986), because the area of possible ulceration remains undeleted.

 Thus, the development of new methods of surgical treatment, allowing to obtain good functional results and reliably relieve relapse of gastric ulcer is an urgent task of surgery.

 The following methods of surgical treatment of ulcers of lesser curvature of the body of the stomach were taken as analogues.

 1. Selective gastric vagotomy with pyloroplasty (Shalimov AA, Maenko VF Surgery of the stomach and duodenum, Kiev .: Health, 1972, p. 106-115).

 After laparotomy, the left lobe of the liver is mobilized by dissecting the triangular ligament, the peritoneum covering the esophagus is dissected, and the anterior vagus nerve is secreted. After stretching the stomach, the gastric branches of the vagus are visualized, which intersect. Find the posterior vagus, tighten the stomach and cross the main trunk below the discharge of the celiac branch, as well as the branch going to the cardia and the bottom of the stomach. Then, pyloroplasty is performed without opening the stomach. The pylorus is introduced into the wound, above it the serous membrane is cut across the axis of the stomach, the muscle pulp is secreted and excised for 1.5-2 cm. Nodal sutures are applied to the serous layer.

Disadvantages:
a). Due to the complete denervation of the stomach and the destruction of the pylorus, their motor-evacuation function is disrupted, which leads to the occurrence of post-vagotomy syndromes, dumping reactions, and bile reflux gastritis.

 b) The ulcer and the entire area of potential ulceration remain undeleted, which entails a relapse of the peptic ulcer.

 2. Transverse resection of the stomach with preservation of the pyloric pulp (Gorbashko AI, Batchaev A.Kh. Soviet medicine, 1980, N 1, p. 68-74).

 A large curvature is mobilized within the resected part of the stomach, preserving the main trunks of the gastrointestinal arteries. Parietal, preserving the main trunks of Lather’s nerves, mobility of lesser curvature is mobilized. The proximal resection line runs between the first transverse branch of the left gastric artery on the lesser curvature and the point located 2 cm above the point of entry into the gastric wall of the last gastric branch of the left gastric omental gland on the greater curvature of the stomach. The small curvature of the proximal stump is sutured. The distal line of resection runs 2 cm above the pylorus, and they try to remove the antrum mucosa as much as possible. A gastro-gastric anastomosis is formed by a double-row suture.

 Disadvantages.

 1. The entire antrum, which has an important trophic function for the gastric mucosa, is removed, which violates gastric digestion.

 2. Most of the branches of the distal "goose paw" of the Latherge nerve intersect, thereby violating the full pulp-and-valve mechanism of the pylorus.

 As a prototype, the method of pyloropreserving resection of the stomach, proposed by L.A. Kovalchuk (Kovalchuk L.A. Surgery, 1988, No. 3, pp. 29-34), was taken.

 The small curvature of the type of SPV and the section of large curvature, respectively, to the resection zone, are mobilized. A segment of the stomach with a distal border is removed: along the lesser curvature above the confluence of the branches of the "goose paw" of the Laterger nerve, along the greater curvature - 2-4 cm above the pylorus; proximal: the lesser curvature of the esophagus-gastric junction, the greater curvature - respectively, the border of the antrum and the body of the stomach (Fig. 1, a). The proximal stump is sutured from the side of lesser curvature to the size of the distal stump and anastomosis is applied end to end with a two-row suture (Fig. 1, b).

 Disadvantages.

 1. Most of the antrum is removed along with the preantral sphincter, which has an important trophic and motor function, especially in conditions of atrophic gastritis, usually accompanying gastric ulcer.

 2. Duodeno-gastric and gastroesophageal reflux, which is present in most patients and contributes to the occurrence of proximal reflux gastritis and reflux esophagitis, is not eliminated.

 3. Due to the application of anastomosis in the entire lumen of the stomach, loss of the preantral sphincter and the ability of the proximal part of the stomach to hold the food lump, the load on the pylorus increases and the evacuation of food in the duodenum is accelerated, which predisposes to the development of dumping syndrome, and overload of the pylorus and duodenum leads to a violation their motility and increased duodeno-gastric reflux.

 The aim of the invention is to increase the effectiveness of surgical treatment of gastrointestinal ulcers, reduce the number of post-gastroresection syndromes and relapse of ulcers, improve the quality of life of patients.

 Tasks.

 1. To study the anatomy of the mediogastric ulcers of the stomach in terms of changes in the topography of the gastric branches of the vagus nerve and Laterger nerve under conditions of inflammatory infiltration and cicatricial transformation of the lesser omentum and the walls of the lesser curvature of the stomach body.

 2. To develop a method for the surgical treatment of ulcers of lesser curvature of the body of the stomach, including a set of surgical technologies that ensure the removal of the entire zone of ulceration; preservation of the main gastric nerves involved in the inflammatory and cicatricial ulcer, extending to the lesser omentum, and the innervated antrum with its motor-evacuation and trophic function; uncoupling of the acid-producing chamber of the stomach and alkalizing; restoration of the reservoir function of the fundus and increased contact time of food with acidic gastric juice; organization of delayed supply and portioning of the food lump in the antrum; preventing overload of the pyloric sphincter and duodenum, as well as reflux of the contents of the stomach into the esophagus, and the contents of the duodenum and alkaline antrum chamber into the acid-producing chamber of the stomach.

 The essence of the proposed method consists in performing SST outside the zone of ulcerative infiltration of the lesser omentum, medial angular subtotal resection of the body of the stomach while preserving the innervated antrum and leaving the crater of the ulcer with demucosed edges of the walls of the stomach along the edge of the ulcer infiltrate on the lesser omentum, and creating a two-chamber calcareous stomach with Carporo-antral anastomosis and restoration of areflux cardia by the creation of invagination esophago-cardio-fundal Foot valve.

 The method is as follows.

 Along the edge of the esophageal opening of the diaphragm (AML), at its left leg 1 (Fig. 2), we dissect the esophageal-diaphragmatic ligament, tighten it with an esophagus and cardia with a tuffer. Next, dissect the diaphragmatic-cardiac and diaphragmatic-fundus ligaments. Thus, the mobilization of the abdominal esophagus 2 (Fig. 2) and cardia 3 (Fig. 2) is performed. The cardia is reduced 1.5-3 cm down, i.e. the abdominal esophagus is lengthened. The front trunk of the vagus is distinguished and the level of the cardia is determined - by the entry of the upper cardial "paw" of the Laterger nerve. The abdominal section and the cardia, by the type of PCV, are skeletal from top to bottom to the level of intimate cicatricial fusion or ulcerative infiltrate around the crater penetrating into the small omentum ulcers 4 (Fig. 2). Then, from the corner of the stomach (above the point of entry of the first branch of the distal "goose paw" of the Lather 6 nerve (Fig. 2), the lesser curvature skeletons up to the lower edge of the cicatricial fusion or ulcerative infiltrate 5 (Fig. 2)). After this, parietally, preserving the main trunks of the gastrointestinal arteries 8 (Fig. 2), a large curvature of the stomach body is skeletonized at the resection level, i.e. from the antrum 7 (Fig. 2) to the first two branches 9 (Fig. 2) of the left gastrointestinal artery, and through the extensive window thus formed, the abdominal esophagus and cardia are skeletoned from top to bottom to the level of cicatricial fusion or ulcerative infiltrate in the small omentum , and from the corner of the stomach from the bottom up - to the lower edge of ulcerative adhesions or infiltrate under visual control of the preservation of the posterior nerve of Laterger and his distal "paw". At the border of the unchanged wall of the stomach (Fig. 3) and the edge of dense cicatricial adhesions or ulcerative infiltrate, we open the stomach and cut it off from the ulcer 2 crater remaining on the small omentum (Fig. 3) or a dense scar. We remove granulation from the crater of the ulcer and sections of the gastric mucosa remaining at its edges.

 After the mobilization of the body of the stomach performed in this way, we perform a segmental subtotal angular resection of the stomach body, taking the entire proximal part of the lesser curvature from the cardia to the angle of the stomach: distally along the border of the antrum and body, proximal from the border of the cardia and body angularly, so that form a strictly cylindrical tube 6-8 cm long with a diameter of 2-2.5 cm from the stored area of large curvature of the body.

 To do this, from the side of great curvature we put two parallel clamps on the future distal end of the tube being formed, we cut the wall of the stomach between the clamps. The next two parallel clamps with a brush length of 6-8 cm are applied at an angle of 90 degrees to the first along a line going up parallel to the large curvature, at a distance of 3 cm from it. We cut the stomach between the clamps. Along the line from the border of the cardia and the body from the side of the lesser curvature of the stomach to the noses of long clamps, we expose the submucosal layer, stitch and bind its vessels for the purpose of hemostasis, and stitch the stomach with a UKL apparatus. Above the apparatus, we cut off the body of the stomach from the fundus. Tantalum submucosal suture is re-toned with individual nodular serous-muscular-submucosal sutures 8 (Fig. 4) with 4/0 monofilament.

 Above the clamps on that part of the stomach, which is intended for the formation of the tube, we dissect the serous-muscular layer and for the purpose of hemostasis we bind the vessels of the submucosal layer. With a single-row nodular serous-muscular-submucous precision suture with a monofilament suture 4/0, we sew the small curvature of the formed gastric tube 7 (Fig. 4).

 We put a clamp on the border of the antrum and the body of the stomach, we cut the body above it and remove the resected segment.

 After that, we again create the Giss angle. We take the esophageal-cardial transition to the holder 6 (Fig. 4) from a thin polyvinyl chloride tube and pull it down, creating an acute angle between the esophagus 4 (Fig. 4) and the large curvature of the fundus 1 (Fig. 4). We impose an 8-shaped suture 3 (Fig. 4), capturing the greater curvature of the fundus of the stomach 1 (Fig. 4), near-esophageal tissue and the edge of the AML 2 (Fig. 4) with the remains of the esophageal-diaphragmatic ligament.

 We restore the esophageal-gastro-diaphragmatic ligaments with three sutures, grabbing with two of them the front wall of the bottom of the stomach 1 (Fig. 5), peri-esophageal tissue and the left leg of the AML (sutures 2,3; Fig. 5) and one - the back wall of the bottom of the stomach and the left leg under (seam 5; Fig. 5).

 Using lateral invagination method, we create an areflux esophago-cardio-gastric valve. To do this, we lay on the front and back walls of the fundus of the stomach on the abdominal part of the esophagus 4 (Fig. 5), the latter is easily immersed in the created “sleeve” with a tuffer and fixed with several sutures 6 (Fig. 5).

 Under the clamp remaining on the cult of the antrum, after dissection of the serous-muscular membrane, we flash and bandage the vessels of the submucosal layer. From the side of small curvature, the stump of the antrum is sutured to the diameter of the formed tube 5 (Fig. 4). Using a single-row nodular precision serous-muscular-submucosal suture with a 4/0 monofilament, we create a corpus antral gastric anastomosis 1 (Fig. 6; 7), which by the method of lateral invagination using 5-6 separate nodular serous-muscular sutures 2 (Fig. 7), stitching the walls of the antrum 3 (Fig. 7) and the gastric tube 4 (Fig. 7) at a distance of 2-3 cm from the seam line of the anastomosis, immersed in the antrum (Fig. 8).

 As a result, a two-chamber stomach is formed, consisting of a fundus acid-producing chamber 1 (Fig. 8), passing into the antrum 2 (Fig. 8) through a narrow cylindrical gastric tube 3 (Fig. 8), which is invaginated into it, providing portion advancement of the food lump and preventing the bile from the duodenum and antrum into the body of the stomach.

 We close the penetrating ulcer sump with an omentum on the vascular pedicle, and we also close the suture lines with it so that the latter do not fuse with the liver and diaphragm. The window in the large gland is closed with separate interrupted sutures 4 (Fig. 8). Between the fundus and antrum of the stomach in the area of the newly created “pylorus” we form a ligamentous apparatus from the omentum, which prevents the created valve from being desenvaginated.

 The method was tested on 36 patients.

 1. Patient I., 53 years old, was admitted to the hospital on 04/04/80 with a diagnosis of gastric ulcer. A peptic history of about 3 years, was repeatedly treated conservatively. The last exacerbation lasted 4 weeks, underwent a course of conservative treatment in the therapeutic department, but the ulcer only slightly decreased in size. At admission, pain in the epigastrium was disturbing, aggravating 15-30 minutes after eating. On FGDS - a chronic ulcer of the middle third of the lesser curvature of the stomach body measuring 1.0 x 0.8 x 0.3 cm, with a pathological and histological examination of the biopsy sample - chronic inflammation. Operated on April 12, 80. During the audit, in the middle third of the lesser curvature, pronounced infiltration of the lesser omentum was found according to the location of the ulcer. They mobilized and reduced the abdominal esophagus, cardia and fundus of the stomach. According to the type of PCV, denervation and devascularization of the anterior wall of lesser curvature from the esophagus to the upper border of the ulcerative infiltrate and from the angle of the stomach to the lower border of the ulcer were performed. Greater curvature was mobilized parietally from the border of the antrum and body to the level of the lower pole of the spleen with the preservation of the first two branches of the left gastrointestinal artery. Through the resulting window in the large omentum, the mobilization of lesser curvature from the back wall was completed with visual inspection of the safety of the posterior nerve of Laterger. Along the border of a healthy wall and the edge of ulcerative infiltration, the stomach was cut off from the small omentum, leaving ulcers on the last crater. After applying clamps to the border of the antrum and the body of the stomach, the latter was cut off. From the esophagus-cardiac transition from the lesser curvature, the serous and muscle layers were dissected along the resection line, the vessels of the submucosal layer were bandaged, the mucous and submucosal layers were stitched with an UKL apparatus, after which the stomach body was removed leaving a section of large curvature to form a 6 cm long tube. Mechanical tantalum the seam was peritonized with a monofilament nodular sero-muscular suture. The side wall of the formed tube was sutured with a single-row nodular submucosal-muscular-serous suture. Areflux cardia was created by lateral invagination. Separate interrupted sutures restored the esophageal-diaphragmatic and gastro-diaphragmatic ligaments. The stump of the antrum from the lesser curvature was sutured to the diameter of the formed tube, which was connected to the antrum with a single-row submucosal-muscular-serous suture. Anastomosis was invaginated in the antrum and secured with six serous-muscular sutures. The suture lines on the stomach were freely covered with an omentum to prevent the formation of adhesions. The ulcer crater was scraped with a scalpel, treated with alcohol and plugged with an omentum. For postoperative decompression of the stomach, a nasogastric polyvinyl chloride probe was performed beyond the anastomosis line. The postoperative period was uneventful. From 2 days the patient was allowed to drink, on the 4th day the nasogastric tube was removed, from 5 days they were allowed to eat. On the 11th day the patient was discharged from the hospital. When examining 6 months after the operation, the patient did not complain, he did not adhere to a special diet. The evacuation of contrasted food from the fundus chamber to the antrum is slowed down to 3 hours, portioned. The gastric tube was transformed from a cylindrical to a conical one. There are no signs of reflux gastritis and reflux esophagitis. 10 years after the operation, the patient feels fine, works in the specialty, does not adhere to the diet.

 2. Patient L., 42 years old, was admitted to the clinic 2.02.94 g with a diagnosis of gastric ulcer. For about 10 years, the patient was disturbed by dyspeptic symptoms, but she did not consult a doctor. A year ago with FGDS, an ulcer of the middle third of the body of the stomach was discovered. It was treated conservatively, a course of endoscopic treatment was carried out, but after three months there was an exacerbation. Upon admission to the FGDS along the lesser curvature at the border of the middle and lower third of the body of the stomach, a peptic ulcer 1.5 x 1.0 x 0.4 cm, with callous edges. With a biopsy, a chronic ulcer. Operated on 8.02.94, after performing the upper middle laparotomy and revision of the abdominal cavity, significant ulcerative infiltration of the small omentum was revealed at the border of the upper and middle third of the lesser curvature. SPV was performed from top to bottom to the ulcer and from the corner of the stomach from the bottom up to the ulcer. Then mobilized a large curvature from the border of the antrum and the body of the stomach for 10 cm, while maintaining one branch of the left gastro-omental gland. Finished mobilization of small curvature from the back wall. Along the border of the ulcer and the healthy wall of the stomach, the latter was cut off from the small omentum, leaving an ulcer crater on it. After preliminary dissection of the serous-muscular layer and ligation of the submucosal vessels, the UKL apparatus was used to flash the newly formed small curvature from the esophageal-cardial transition with subsequent peritonization of the mechanical suture. The gastric body was resected stepwise, leaving a section of great curvature to form a tubular anastomosis, and the removed section was cut off along the border of the antrum and body. Then, with a single-row nodular precision suture, the small curvature of the created tube was sutured with monofilament and the areflux cardia was formed by lateral invagination. The esophageal-gastro-diaphragmatic ligaments were restored. The stump of the antrum from the side of lesser curvature was sutured to the diameter of the tube and an invagination corporeal-antral anastomosis was formed. A nasogastric tube was performed in the antrum. The line of seams was freely covered with an omentum. The ulcer crater was treated and plugged with an omentum. The postoperative period was uneventful. From the 3rd day the patient began to drink, on the 5th day the nasogastric tube was removed, after which they were allowed to eat. On the 13th day the patient was discharged from the hospital. When examined after 6 months, no complaints, diet does not comply.

 Using the method allows to cure gastric ulcer and prevent its relapse. The high functionality of the proposed operation allows you to quickly restore full gastric digestion, provides portioned advancement of food along the esophagus - stomach - duodenum, prevents the development of reflux esophagitis and biliary reflux gastritis, minimizes the possibility of post-gastro-resection and post-vagotomy syndromes. Thus, the application of the method leads to a quick and reliable recovery of patients, returning them to normal life and work without the need to adhere to any special diet and diet, provides them with a high quality of life.

Claims (1)

 A method of surgical treatment of ulcers of lesser curvature of the body of the stomach, including selective proximal vagotomy, segmental resection of the stomach and the formation of a gastro-gastric anastomosis, characterized in that selective proximal vagotomy for lesser curvature of the stomach is performed outside the zone of ulcerative infiltration of the lesser omentum, then medial angular subtotation is performed. stomach with the condition of maintaining the innervated antrum and leaving the ulcer crater in the small omentum, restore areflu creation of invaginated clarity cardia esophago-cardio-fundic valve and create a two-chambered stomach by forming a tubular invaginated areflux Corpora-antral anastomosis.

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