RU2122834C1 - Method of preventing duodenogastral reflux in surgical treatment of ulcers of duodenum bulb - Google Patents

Abstract

FIELD: gastroenterological surgery. SUBSTANCE: tubular stomach resection is performed according to Bilerot-I procedure. Functionally active sphincter is formed from duplicated serous-muscular layer of stump of stomach, and valve-cusp is formed on the anterior semicircle of anastomosis. Simultaneously, mucous-submucous layer of stomach and duodenum are sutured going along anterior semicircle of anastomosis. Preliminarily, mucous-submucous layer of stomach is intersected over arched line with its apex facing duodenum. Serous-muscular layer of the latter is, also preliminarily, twice incised. Circular incision passes lower edge of ulcer and arched one faces, with its apex, stump of stomach. Valve-cusp is inserted into duodenal lumen applying second series of sutures. EFFECT: reduced duodenogastral reflux thanks to additional obstacle for back spreading of chyme from duodenum into stomach stump. 6 dwg

Description

 The invention relates to medicine, namely to surgery of the stomach and duodenum, and can be used for the prevention of duodenogastric reflux in the surgical treatment of ulcers of the duodenal bulb.

 Closest to the proposed method is a method for the prevention of dumping syndrome [1] by forming the pulp of the stump of the stomach during its resection (according to the copyright certificate N 942717. Bulletin of the invention N 26, 1982) However, the frequency [2] of post-gastroresection syndromes (12.7%) and in particular, duodenogastric reflux of the II - III degree in the short term after surgery in 23.5% of patients and in 9% of those examined in the long-term postoperative period makes it necessary to improve the reflux qualities of gastroduodenoanastomosis.

 A new technical result - reducing the frequency of duodenogastric reflux after resection of the stomach by creating an additional obstacle to the reverse reflux of the chyme from the duodenum to the stump of the stomach, is achieved by a new method for the prevention of duodenogastric reflux, including tubular resection of the stomach according to the Billroth-I method, the formation of a functionally active pulp on the cuff stomach, and on the front semicircle of gastroduodenoanastomosis form a "valve-leaf" by stitching continuous submucous a stitch seam remaining on the anterior semicircle of the stomach stump distal to the pulp of the mucous-submucosal layer, cut along the arcuate line, with the apex facing the duodenum, and the mucous-submucosal layer of the anterior semicircle of the bulb of the duodenum, which remained after detachment of the duodenal mucosa of the serous the intestine between two sections of the serous-muscular membrane - the first circular and second along the arcuate line, the apex facing the stump of the stomach and, a cut mucous and submucous layers of submucosal crosslinked continuous suture and the second node adjacent gray-serous seam formed immersed "flap valve" in the duodenum.

The method is as follows:
Stomach is mobilized by large and small curvature. The stomach is cut off from the duodenum between the tantalum sutures imposed by the UO-60 apparatus. Mark the boundaries of the resection. By large curvature, the wall of the stomach is taken to the first holder. A perpendicularly large curvature from the first holder is 2 - 3.5 cm through the two walls of the stomach impose a second holder. A third holder is applied 1 cm below the descending branch of the left gastric artery. The stomach is stretched with arms. From the side of lesser curvature on the removed part of the stomach, lower by 1 cm of the third holder, impose a L-shaped clip in the direction of the second holder. The serous-muscular layer is circularly dissected with a scalpel along the lower edge of the clamp to the second holder and from it to the first holder. Dissected muscle membranes, contracting, expose the submucosal layer up to 1 cm wide. With the help of UO-60, mucous membranes are sutured from the side of small curvature. From the side of great curvature, the mucous membranes are flashed with the UO-40 device. Below this suture, 1 - 2 cm on the removed part of the stomach, a clamp is applied, the removed part of the stomach is cut off along the upper border of the clamp from the side of great curvature to the second holder. Using the UO-60 device, mucous membranes are stitched to meet the tantalum suture imposed from the side of small curvature. The removed part of the stomach is cut off. In order to ensure reliable hemostasis from the side of the lesser curvature of the stomach stump, the mechanical suture is additionally sheathed with a continuous catgut suture from the third arm to the second. Nodular sero-muscular sutures cover a mechanical suture. The mucous membranes of the lower end of the tube are taken onto the holders. At the distal end of the stomach stump, an artificial pulp is formed, consisting of a duplicate of the serous-muscular membrane. Take the edge of the serous-muscular membrane with tweezers and pull it upward, and serous-muscular membrane is separated with a scalpel or thin scissors along the entire circumference of the stomach stump 10-12 mm wide. Separated serous-muscular membrane is wrapped up (Fig. 1). Separated seams of the serous-muscular membrane are sutured to the serous membrane of the stomach along the entire circumference to a lesser curvature, where a “lock” is formed from the mobilized serous-muscular membrane. For this, the serous-muscular membrane of the posterior wall is slightly stretched and sutured to the serous membrane of the anterior wall of the stomach, after which the serous-muscular membrane of the anterior wall is also slightly stretched and hemmed to the serous membrane of the posterior wall. This creates an analogy of muscle pulp at the distal end of the stump of the stomach. Distant to the lower edge of the pulp, the mucous membrane of the stump of the stomach is left up to 20 - 25 mm long. The visible vessels of the submucosal layer are sutured with catgut on the remaining mucous-submucous layer of the stomach stump. Moreover, in the posterior semicircle of the stump, the vessels are sutured below the lower edge of the pulp by 2–3 mm, and in the front semicircle of the stump, the vessels are stitched in an arcuate line, the apex of which is distally from the pulp and distant from its lower edge by 15–18 mm (Fig. 2) . The duodenal stump is taken on the holders. On the lower edge of the ulcer on the posterior semicircle of the duodenum, the sero-muscular membrane of the intestine is circularly dissected, exposing the submucosal layer at a width of 5 - 8 mm. The circular incision is continued to the anterior semicircle of the duodenum. On the anterior semicircle of the intestine, proximal to the circular incision, a second incision of the serous-muscular membrane is performed. The section begins from a circular section on the lesser curvature, an arcuate line is described with the apex facing the pyloric pulp, and ends at a circular section on the serous-muscular membrane on a large curvature. The distance between the circular incision of the serous-muscular membrane of the duodenum and the apex of the arcuate line is 15 - 18 mm. The serous-muscular membrane between the incisions is separated, while the mucous-submucosal layer on the anterior semicircle of the duodenum is released (Fig. 3).

 They begin to impose gastroduodenoanastomosis. 5-6 nodular gray-serous sutures are placed on the posterior wall. On the cult of the stomach, the lower edge of the pulp is taken into the suture, and on the duodenum - the serous-muscular membrane with a puncture at the edge of the incision. The seams are tied. Next, a mucous-submucous layer of the right corner of the anastomosis is sutured with a catgut thread on an atraumatic needle up to 40-50 cm long, the thread is stretched halfway and tied. The left corner of the anastomosis is also stitched in the same way. Then, one of the threads of the right corner of the anastomosis is sutured with a continuous suture of the submucosal-mucous layer of the posterior wall of the anastomosis to its middle. One of the threads of the left corner is sutured to the other half of the posterior lip of the anastomosis. The threads are tied - the back wall of the anastomosis is formed (Fig. 4). Above this suture, 1 - 2 mm open the lumen of the stump and intestine. On the posterior lip of the anastomosis, the remaining sections of the stump and intestine are cut off along the mucous-submucosal suture. On the anterior semicircle of the stump, the cut-off goes along the vessels of the submucosal layer stitched along the arc, thus the proximal part of the “valve-leaf” is cut out. On the anterior semicircle of the duodenum, clipping takes place along an arcuate line, thus the distal part of the “valve-sash” is cut out. The remaining catgut sutures in the same sequence sew the submucosal layer of the anterior semicircle of the anastomosis to its middle on the right, then on the left. The threads are tied (Fig. 5). 5 to 6 gray-serous sutures are placed on the anterior semicircle of the anastomosis. On the cult of the stomach, the lower edge of the pulp is taken into the suture, and on the duodenum, the serous-muscular membrane. When tying the seams "valve-sash" by the dissector is immersed in the lumen of the duodenum (Fig. 6). The wound of the anterior abdominal wall is sutured in layers tightly.

 Example: (Extract from the medical history) Patient R., 28 years old, was admitted to the I surgical department of the city hospital No. 2 with complaints of aching pain in the epigastric region, right hypochondrium, hungry, night pain, heartburn, nausea. A peptic history for five years, annually underwent a course of conservative antiulcer therapy inpatiently, but relapses occurred after 5-6 months.

 During the examination: Fibrogastroscopy - the gastric mucosa in all sections is hyperemic, in the distal section there are many complete erosions. There is a little bile in the stomach. Pylorus pass. The duodenal bulb is deformed. On the medial wall there are two ulcers - one 1 cm in diameter with fuzzy edges, covered with fibrin, deep, near the second ulcerated ulcer of 0.2 - 1.0 cm, covered with fibrin. The duodenal bulb is hyperemic, swollen.

 During a fluoroscopy of the stomach, the pyloric department is deformed, the evacuation is slowed down, the duodenal bulb is deformed. There is a barium depot up to 0.8 cm with an infiltrated shaft around and a deep ulcerative niche along the medial contour 1.0 - 1.0 cm. The mobility of the bulb is limited. Evacuation into the duodenum is slow. Distinct bulbo-gastric and duodenogastric reflux.

 Clinical diagnosis: Duodenal ulcer, continuously recurring course. Deformation of the duodenal bulb. Duodenogastric reflux II degree. Bulbit. Compensated duodenostasis.

 The operation was performed - resection of 1/2 of the stomach according to the method of Billroth - 1 with the formation of pulp on the cult of the stomach and "valve-sash" according to the described method.

 The patient was discharged on the 8th day after the operation. When examining in the period from 2 months to 2 years after the operation, he does not show any complaints, does not follow a diet, gained 5 kg in weight, is able to work, there are no signs of reflux gastritis, dumping syndrome.

 The shape of the created “valve-leaf” resembles the physiological fold of the mucous membrane of the pyloric canal. This is achieved by cutting out the submucosal layers of the stump of the stomach and duodenum along the arcuate line, since this shape corresponds to the geometry of physiological folds. Stitching of the submucosal layers with a continuous submucosal suture with an oncoming catgut suture ensures matching of homogeneous tissues, healing takes place by primary intention, deformation of the intestinal lumen and cicatricial changes, fixation of the angles of the anastomosis at four points are eliminated. The location of the “valve - sash” distal to the pulp is dictated by the best conditions for creating a barrier to the return of the chyme from the duodenum to the stump of the stomach.

 Thus, the proposed method for the formation of gastroduodenoanastomosis with pulp and “valve flap” is an artificial model in form and function similar to the normal pyloroduodenal transition, where the function of pyloric pulp is performed by artificial pulp, and the normal folds of the mucous membrane of the pyloric canal are replaced by a “valve flap” .

 The proposed method for the formation of gastroduodenoanastomosis was applied in an experiment on 10 outbred dogs - morphological examination of the pulp and “valve flap” showed the presence of successive phases of the development of aseptic wound inflammation and reparative regeneration, indicating the absence of dystrophic and degenerative changes, healing of the anastomosis by primary tension without formation rough scar. In clinical conditions, the method was applied in 12 patients with peptic ulcer of the duodenal bulb. As a result of clinical observations and examination of patients from 2 months to 2 years after surgery, it can be concluded that the use of the proposed method for the formation of gastroduodenoanastomosis after gastric resection in the surgical treatment of duodenal ulcers reliably prevents gastritis reflux.

List of sources of information:
1. USSR copyright certificate N 942717, 1982.

 2. Zherlov G.K., Dambaev G.Ts. Resection of the stomach with artificial pulp in the area of anastomosis in the surgery of gastroduodenal ulcers. Tomsk University Press, 1993.

Claims (1)

 A method for the prevention of duodenogastric reflux in the surgical treatment of duodenal ulcers, including a tubular resection of the stomach according to Billroth-1, the formation of a functionally active pulp consisting of duplicature of the serous-muscular layer on the gastric stump, characterized in that a valvular duct anastomosis is formed on the anterior semicircle stitching with a continuous submucosal suture of the stomach stump remaining on the anterior semicircle is distal to the pulp of the mucous-submucous layer cut out an arcuate line with the apex facing the duodenum, and the mucous-submucosal layer of the anterior semicircle of the duodenal bulb, which remained after separation of the serous-muscular membrane in the anterior semicircle of the duodenum between the two sections of the serous-muscular membrane, the circular and arcuate, starting from circular on the lesser curvature, with the apex facing the cult of the stomach, and ending at the circular incision on the greater curvature, then the second row of seroserotic sutures immerse the formed valve-leaf into the lumen of the duodenum.

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