RU2124863C1 - Method of surgically treating duodenal ulcer diseases combined with chronic disorders in duodenal permeability - Google Patents

Abstract

FIELD: abdominal surgery. SUBSTANCE: vagotomy is performed, stomach is resected with preservation of pylorus, and serous-muscle flap is raised at the distance 1.5-1.8 cm from pylorus. Thereafter, mucous membrane of pyloritic portion is pulled up in direction of stomach portion being removed by 0.5-0.8 cm. Mucous membrane is cut off on the level of serous-muscle incision and duodena is then resected segmentarily with complete mobilization of proximal portion. Terminal branches and intrapancreatic arteries are intersected from the two ends of intestine at distance not exceeding 0.5-0.7 cm. Anastomosis is applied equidistantly from sphincters of duodena and small intestine, actuating loop is fixed on the root of mesentery of transverse colon at distance 2-3 cm. EFFECT: prevented recurrence of ulcer and reflux gastritis. 8 dwg, 2 ex

Description

 The invention relates to medicine, namely to gastroenterology, and can be used for the surgical treatment of peptic ulcer of the duodenum, complicated by stenosis and penetration into the head of the pancreas and combined with chronic disorders of duodenal patency.

 Closest to the claimed solution is a method of surgical treatment of peptic ulcer of the duodenum by performing selective proximal vagotomy with cutting serous-muscular flap according to the lesser curvature, resection of the stomach and resection of the duodenum, followed by the application of gastropiloroanastomosis and duodenodenodenodenodenitis M. .Myasnikov, G.I. Yangolenko "Method for the surgical treatment of peptic ulcer of the duodenum", ac N 2027406).

 However, the use of this method in the surgical treatment of peptic ulcer of the duodenum, combined with chronic disorders of duodenal patency, is not effective enough, as in some patients in the long term there is a relapse of peptic ulcer and reflux gastritis.

 The objective of the invention is to prevent relapse of peptic ulcer and reflux gastritis.

 The task is carried out by the fact that they begin to cut out a serous-muscular flap, departing 1.5 - 1.8 cm from the pylorus, pull the mucous membrane of the pyloric department towards the removed part of the stomach by 0.5 - 0.8 cm, after which it is cut off the level of the serous-muscular section of the remaining part of the pyloric department, then, after segmental resection of the duodenum, the proximal part is fully mobilized, and the terminal branches and intrapancreatic arteries cross from the both ends of the intestine at a distance of not more than 0 , 5 - 0.7 cm, after which a longitudinally-transverse duodenojejunomastomosis is applied at an equidistant distance from the sphincters of the duodenum and jejunum and fixation of the lead loop to the root of the mesentery of the transverse colon at a distance of 2-3 cm.

 In FIG. 1-3 are diagrams illustrating the invention.

 The method is as follows. Perform upper middle laparatomy. The duodenum is mobilized and taken to the wound. Selective proximal vagotomy is performed and the sero-muscular flap is cut out (4, Fig. 1), 1.5-1.8 cm indent from the pylorus, and the cut continues to the angle of the stomach. At the same time, intraorgan ligation of the branches of the right gastric artery is performed, thus preserving the vegetative innervation of the pyloric stomach (5, Fig. 1). The mobilization of the stomach along a large curvature is carried out in a volume of 2/3, starting proximal to the pylorus by 1.5 - 1.8 cm and preserving the gastrointestinal arteries by ligating their second-order branches. The pyloric-pancreatic ligament is then dissected, and between the terminal branches of the gastroduodenal artery and other main arteries, tunnels are made with a dissector or clamp like a mosquito without crossing the terminal branches, and thus mobilization of the proximal part of the duodenum begins, preparing it for duodenoplasty (4 .2).

 After this, a circular resection of 2/3 of the stomach is performed at the level of its mobilization. At the same time, the distal end of the removed part of the stomach is cut off from the pyloric department in such a way as to remove the mucous membrane of the pyloric department as much as possible. To do this, along the line of the proposed resection of the stomach, spaced from the pylorus at a distance of 1.5 - 1.8 cm (7, Fig. 1), cut the wall of the stomach to the submucosal layer, cutting it which pulls the mucous membrane of the pyloric department towards the removed part of the stomach (6, Fig. 1) 0.5 - 0.8 cm (3, Fig. 1). After that, the mucous membrane is cut off at the level of the serous-muscular section of the remaining part of the pyloric stomach. Then, gastropylororoanastomosis is formed, end-to-end, and strengthened by a slight curvature with a serous-muscular flap (1, Fig. 3).

 The size of the remaining part of the pyloric stomach equal to 1.5 - 1.8 cm, which is devoid of the mucous membrane by 0.5 - 0.8 cm, established by the data of a clinical study. With an increase in the size of the pyloric department, some patients experience hyperproduction of hydrochloric acid, while a decrease in these sizes increases the likelihood of pyloric spasm. This technique of treating the pyloric department with the maximum possible removal of the mucous membrane leads to minimal stimulation of gastrin by the remaining endocrine G-cells, which leads to the production of hydrochloric acid, which does not exceed normal values. This is one of the factors in the prevention of peptic ulcer.

 After that, perform segmental resection of the duodenum. For this, the lateral walls of the duodenum are mobilized parietally in the area of cicatricial narrowing, after which a transverse duodenotomy is performed along the front wall to the side to the edges of the penetrating ulcer (1, Fig. 2). Above and below the ulcerative crater, the dissector performs tunnels between the intestine and pancreas, after which the posterior wall of the duodenum is crossed through the tunnels. Then, the edges of the posterior walls of the intestine are isolated from the ulcer crater in the proximal and distal directions from the cicatricial adhesions that cross. To achieve sufficient mobility of the ends of the duodenum, further mobilization is made from the posterior and lateral walls. To do this, the posterior wall is separated from the pancreas, and the side walls from the lesser and greater omentums, creating tunnels in the loose posterior-posterior tissue with a dissector between the terminal branches of the main arteries (right gastric and gastro-omental, upper anterior and posterior pancreatoduodenal) (8, Fig. 2 ) and intrapancreatic arteries (6, Fig. 2) in the proximal direction to the pylorus and in the distal direction to the base of the large (5, figure 2) (or small) duodenal papilla so as not to damage last (3, figure 2). Thus, the proximal part of the duodenum is fully mobilized.

 Then, the most economical resection of the cicatricial ends of the duodenum is performed, after which the terminal branches (7, Fig. 2) and intrapancreatic arteries (6, Fig. 2) cross at a distance of no more than 0.5 - 0.7 cm from both ends of the intestine. After such mobilization, the distal and especially the proximal parts of the duodenum become well displaced from the “platform” of the pancreas and are comparable without tension. Then, duodenoduodenonanastomosis is applied, forming the posterior lip with one row of catgut or monofilament sutures, and the anastomosis of the front lip with two rows of sutures, the first of them with interrupted sutures, and the second row with U-shaped sutures with sealing the anastomosis corners to the scar tissue on the head of the pancreas.

 This technique of the formation of anastomosis (2, Fig. 3) allows you to create optimal conditions for regeneration in a duodenal wound and is thereby one of the factors in the prevention of relapse of ulcers.

 Then, below the root of the mesentery of the transverse colon to the right and left of the root of the mesentery of the small intestine, the peritoneum is dissected along the lower contour of the duodenum and the duodenum is mobilized along the entire length of the duodenal bend so that all parts of the duodenum are well visualized. After that, the patient is injected intravenously with 0.5 ml of a 0.1% solution of morphine, and after 5 minutes, the Kapanji sphincter in the middle third of the descending part and the Oxner sphincter in the lower horizontal part or the initial segment of the ascending part of the duodenum are determined by spasm of the intestine (9 , Fig. 2), and below the duodenojejunal bend - sphincter of the jejunum, spaced from each other at a distance of 10-20 cm (10, Fig. 2). Then, at a distance of 15 - 20 cm from the duodenojejunal bend with the descending part of the duodenum, a longitudinal suture is placed with a two-row suture in such a way that the incision on the wall of the duodenum is located longitudinally to its axis and at an equidistant distance from the sphincters of the Kapanji and the intestine was located transversely to its longitudinal axis and at an equidistant distance from the sphincter of the jejunum. After that, the jejunum adduction loop is fixed at a distance of 2-3 cm to the root of the mesentery of the transverse colon (1.5, Fig. 3).

 Longitudinal dissection of the duodenum improves the functional properties of the anastomosis in that the peristaltic or antiperistaltic contractions extending to the area of the anastomosis “open” it and thereby effectively evacuate the contents of the duodenum into the jejunum. Cross section of the wall of the jejunum prevents the reflux of intestinal contents into the duodenum through the anastomosis in that the peristaltic or antiperistaltic contractions that extend along the jejunum constrict and "close" it. The location of the anastomosis at an equidistant distance from the sphincters also improves its functional properties, since the spastic contractions that occur in the sphincters do not prevent evacuation through the anastomosis. Fixation of the lead loop to the root of the mesentery of the transverse colon prevents the duodenal contents from being thrown into the lead loop, which, along with the cross section of the jejunum wall, prevents the formation of a “vicious circle”.

 The invention is illustrated by the following examples.

 Example 1. Patient A., 45 years old, medical history N 1457, was from September 4, 1995 in a surgical clinic with a diagnosis of peptic ulcer. Combined postgastroresection syndrome after pyloric preservation of the stomach. Recurrent duodenal ulcer. Reflux gastritis. Chronic disorders of duodenal patency in the stage of subcompensation.

 In 1989, a duodenal gastric resection was performed for duodenal ulcer without taking into account the condition of duodenal patency. 6 months after surgery, a relapse of duodenal ulcer was diagnosed. Conservative treatment of duodenal ulcer over the next 6 years did not give a lasting effect and the patient was admitted for repeated surgical treatment.

 With fibrogastroduodenoscopy, a recurrent ulcer of the posterior wall of the duodenal bulb, reflux gastritis was diagnosed. During a fluoroscopy of the stomach and duodenum, in addition to the ulcer niche along the posterior wall of the duodenal bulb, chronic duodenal patency disorders caused by persistent spasm of the Oxner sphincter, leading to duodenal hypotension and periodically repeated duodenogastric, were diagnosed.

 September 4, 1995 the operation was performed: laparatomy, resection of the stomach with removal of the pyloric department, longitudinally transverse duodenojejunoanastomosis. The postoperative period was uneventful and the patient was discharged in satisfactory condition for outpatient monitoring. Examined 1 year after surgery. Healthy, no complaints. There is no recurrence of ulcer and reflux gastritis endoscopically and radiologically, and chronic duodenal patency disorders are compensated by a well-functioning duodenoeunoanastomosis (Fig. 5).

 Example 2. Patient E., 42 years old, was from 2.10.95, in the surgical department with a diagnosis of peptic ulcer. An ulcer of the posterior wall of the duodenal bulb, complicated by stenosis and penetration into the head of the pancreas. Chronic disorders of duodenal patency in the stage of subcompensation.

 The patient suffers from peptic ulcer for 20 years. Conservative treatment in combination with infusion intraduodenal therapy did not give a lasting effect and the patient was admitted for planned surgical treatment.

 When fluoroscopy was diagnosed with an ulcer of the posterior wall of the duodenal bulb, hypotension of the proximal duodenal ulcer, duodenogastric reflux. To clarify the causes of chronic violations of duodenal patency, duodenography was performed, in which a delayed bowel movement was diagnosed at the level of the lower horizontal part due to persistent spasm of the Oxner sphincter, duodenogastric reflux (Fig. 6).

 The acid-producing function of the stomach: BKP - 6 mmol / h, MCP - 42 mmol / h.

 10/9/95, the operation was performed: laparatomy, pyloroplasty resection of the stomach, segmental resection of the duodenum, longitudinally-transverse duodenoeunoanastomosis.

 Performed upper-middle laparatomy. The stomach is enlarged and its wall is thickened. The duodenal bulb and post-bulbar sections are scarred, and ulceration up to 1 cm in diameter is determined by palpation on the posterior wall of the bulb. A selective proximal vagotomy was performed with intraorgan ligation of the branches of the right gastric artery and cutting out a sero-muscular flap, 1.5 cm indent from the pylorus and continuing to cut to the corner of the stomach. The mobilization of the stomach along a large curvature was performed in a volume of 2/3, proximal to the pylorus by 1.5 cm, with the preservation of the gastrointestinal arteries, by ligating their second-order branches. The pyloric-pancreatic ligament is dissected and tunnels are made between the terminal branches of the main vessels. After this, a circular resection of 2/3 of the stomach was performed. At the same time, the distal section of the stomach is cut off from the pyloric section after pulling the mucosa from the pyloric section by 0.5 cm, after which gastropylooroanatomosis of the end-to-end type is applied. Small curvature is strengthened by a sero-muscular flap. After this, the walls of the duodenum were mobilized in the area of cicatricial narrowing, after which a transverse duodenotomy was made along the front wall with the transition to the lateral to the edges of the penetrating ulcer. Tunnels were made above and below the ulcerative crater and cut off along them, and then the posterior wall of the duodenum was isolated from cicatricial fusion in the proximal and distal directions. To achieve sufficient displacement of the ends of the duodenum, the posterior and lateral walls were further mobilized by performing tunnels between the terminal branches of the main vessels and the intrapancreatic arteries in the proximal direction to the pylorus and in the distal direction to the base of the large duodenal papilla. After this, an economical resection of the scarred ends of the duodenum was performed, after which terminal branches and intrapancreatic arteries were crossed at a distance of 0.5 cm from the ends of the intestine in both directions. After this, duodenoduodenoanastomosis was applied according to the end-to-end type with the formation of the posterior lip of the anastomosis with single-row interrupted sutures, and the front lip of the anastomosis with double-row sutures with sealing of the corners of the anastomosis.

 Below the root of the mesentery of the transverse colon, the duodenum is mobilized. After administration of 0.5 ml of a 0.1% morphine solution, sphincters in the jejunum and sphincters were determined. Kapanji and Oksner in the duodenum, after which at a distance of 20 cm from the duodenojejunal bend and at an equidistant distance from the sphincters of the duodenum and jejunum, a two-row suture between the jejunum and the descending part of the duodenum is placed on the anterior-duodenum. The adducting loop of the jejunum is fixed at a distance of 2 cm to the root of the mesentery of the transverse colon.

 The postoperative period was uneventful. On the 12th day, a fluoroscopy of the stomach and duodenum was performed, in which a portion-rhythmic evacuation from the stomach stump was diagnosed, regulated by rhythmic contractions of the pyloric sphincter, and a normally functioning duodenoeunoanastomosis through which most of the barium is evacuated (Fig. 7). In satisfactory condition, the patient was discharged for outpatient treatment. Examined 1 year after surgery. Is healthy. Acid-producing function of the stomach: BKP - 2 mmol / h, MCP - 18 mmol / h. A control fluoroscopy of the stomach and duodenum was performed, in which a portion-rhythmic evacuation from the stump of the stomach and a normally functioning duodenoeunoanastomosis, normal tone of the proximal duodenum were diagnosed (Fig. 8). Relapse of ulcers and reflux gastritis according to fluoroscopy and fibrogastroduodenoscopy was not found.

 In FIG. 1 shows the cutting of a serous-muscle flap and cutting off the distal part of the stomach with pulling up the mucous membrane of the pyloric department.

 In FIG. 2 shows the execution of segmental resection of the duodenum and the location of duodenojejunostomy.

 In FIG. 3 shows the final view of the operation.

Claims (1)

 A method for the surgical treatment of duodenal ulcer, combined with chronic duodenal impairment, including vagotomy with excision of a serous-muscular flap, gastric resection with preservation of the pylorus, characterized in that it begins to cut out a serous-muscular flap, retreating 1.5-1.8 cm from the pylorus, pull the mucous membrane of the pyloric department towards the removed part of the stomach by 0.5-0.8 cm, after which it is cut off at the level of the serous-muscular section of the remaining part of the pyloric cases, then after segmental resection of the duodenum, its proximal section is fully mobilized, and the terminal branches and the intrapancreatic artery cross from both ends of the intestine at a distance of no more than 0.5-0.7 cm, after which a longitudinal-transverse duodenojunoanastomosis is applied at an equidistant distance from sphincters of the duodenum and jejunum with fixation of the leading loop to the root of the mesentery of the transverse colon at a distance of 2-3 cm.

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