RU2143229C1 - Method of surgical treatment of duodenal peptic ulcer - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: method includes selective proximal vagotomy; dissection of stenosing walls of duodenum; preservation of continuity of intramural innervation; closing of large defect of proximal half of duodenum with displaced walls of distal part of duodenum with bringing of distal part of duodenum from under root of small intestine mesentery. EFFECT: reduced number of postoperative functional disturbances and ulcer recurrences. 4 dwg, 1 ex

Description

 The invention relates to medicine, namely to surgery, and can be used for the treatment of duodenal ulcer complicated by prolonged cicatricial ulcerative stenosis of the proximal part of the duodenum.

 The expansion of the arsenal of antiulcer drugs limits the indications for surgical treatment. This explains the increase in the proportion of “complex” duodenal ulcers, which requires further development of surgical technologies that guarantee the fullness of functional rehabilitation.

 Frequent relapse of peptic ulcer against the background of increased acid-peptic aggression ultimately leads to a complete scar-ulcer transformation of the proximal duodenum. According to our data, from the number of patients operated in 8.4% of patients, the radical elimination of the post-ulcer lesion led to the resection of the duodenum from the pylorus to the large duodenal papilla or peri-papillary level.

 Our many years of experience in plastic surgery of complicated duodenal ulcers revealed the dependence of the completeness of restoration of gastroduodenal complex function on the volume of resection of the proximal duodenum.

 The expansion of the volume of the duodenum resection eliminates the advantages of radical duodenoplasty over palliative shunting of stenosis. A decrease in pyloric papillary diastasis, combined with various variants of pyloric lysis, violates gastric autonomy. The absence of a bulboduodenal sphincter and bulb bulb leads to continuous evacuation from the stomach. Compensatory response spasm of distal intestinal sphincters is the cause of duodenostasis of varying severity.

 Thus, the development of new methods of surgical treatment to improve functional results and relieve relapse of duodenal ulcers is an urgent task for surgery.

 Stem vagotomy with gastroduodenoanastomosis. The method is well known, first proposed by Jaboulay in 1892 (cited by A. Shalimov, V.F. Saenko, 1987).

 After a laparotomy, the left lobe of the liver is mobilized by dissection of the triangular ligament, the visceral peritoneum of the esophagus-gastric junction is dissected, the right and left vagus nerves are distinguished with subsequent intersection. Then, according to Kocher, duodenum is mobilized, a vertical branch is brought to the antrum of the stomach, a gastro-duodenal anastomosis with anastomosis diameter of 4-5 cm is formed.

Disadvantages:
1. Complete denervation of the stomach and bypass of the pylorus violate their motor-evacuation function, this leads to the occurrence of dumping syndrome and reflux gastritis.

 2. The complicated ulcer, scar-transformed walls of the bulb, that is, tubular stenosis, which does not exclude further complications of peptic ulcer (bleeding, penetration, perforation), are not removed.

 As a prototype, a method was taken: segmental duodenoplasty with SPV (Onopriev V.I., patent N 971286 dated December 15, 1980).

 When performing the prototype method, the duodenum is mobilized, its anterior wall is cut transversely above the ulcer or along the line of maximum narrowing, and the rigid edges of the duodenal wall are excised. Isolation of the walls of the intestine is carried out stepwise up and down. Cicatricial and infiltrated tissues are completely excised. After excision of the stenotic segment of the duodenum, its edges are mobilized and freely reduced to the distal, that is, the papillary end, which allows the papillary anastomosis to be applied without tension. The back wall of the anastomosis is sutured with a single-row regional serous-muscular-submucosal suture with 4-6 / 00 nodules inward (absorbable monofilament) or nodules outward (non-absorbable monofilament). The anastomosis anterior wall is sutured with a single-row nodular serous-muscular-submucosal suture (4-6 / 00).

 SPW begins with skeletalization of the esophageal opening of the diaphragm (AML) and its left leg by crossing the esophageal-diaphragmatic, diaphragmatic-cardial and diaphragmatic-fundus ligaments, which allows to extend the esophagus, lower the cardia and the angle of His. Cross the proximal half of the gastro-splenic ligament, pancreas and gastric ligament with blood vessels and nerves. First, the back wall of the esophagus and cardia is skeletonized from behind through a window in the gastro-splenic ligament to the first short artery of the stomach. Then the front wall of the cardia and esophagus is skeletonized, with particular attention paid to the intersection of the branches of the main cardiac nerves. Skeletonization of the lesser curvature of the stomach goes from the cardia to the corner, the "goose foot" of the posterior main gastric nerve is controlled through a window in the gastrocolic ligament at the level of the angle of the stomach. To restore the cardiac closure function, new anatomical relationships are created between the esophagus, cardia and stomach in the form of an esophagocardiogastric valve by lateral invagination with restoration of the ligamentous apparatus.

Disadvantages:
1. The proximal section of the duodenum is removed to the large duodenal papilla, anastomosis performed under these conditions reduces pyloric papillary diastasis, leading to an increase in duodenogastric reflux and the development of reflux gastritis.

 2. Additional mobilization of the pyloroduodenal end, as well as the anatomical features of the papillary zone of the duodenum determine its rigidity, the formation of pyloroduodenal anastomosis at this level prevents the complete restoration of the function of the pylorus.

 3. The creation of a papillary duodenal anastomosis in case of recurrence of an ulcer along the suture line poses a threat to ulcerative damage to the papilla.

 4. The continuity of intramural innervation is disrupted.

 The aim of the invention is to increase the effectiveness of surgical treatment of duodenal ulcer complicated by prolonged cicatricial ulcerative alteration of the proximal duodenum, reduction in the number of postoperative functional disorders and relapse of the ulcer, improving the quality of life of patients in the long term.

 Objective: to develop a method for the surgical treatment of duodenal ulcer complicated by prolonged cicatricial ulcer alteration of the anterolateral proximal walls, suggesting radical removal of the transformed walls with preservation of the pylorus and posterior wall of the gastroduodenal junction, followed by the replacement of the duodenal defect with a mobile anterior duodenal wall.

 The essence of the proposed method consists in maintaining the continuity of the intramural innervation of the duodenum with the radical elimination of tubular stenosis, and replacing the extended defect of the anterior and lateral walls of the proximal half of the duodenum with displaced walls of its distal part, removed from the root of the mesentery of the small intestine. The method is supplemented by SPV.

 The method is as follows.

 Extensive mobilization of the duodenum 1 along with the head of the pancreas 2 is performed. In this case, the cicatricial fusion between the hepatoduodenal ligament 3 and the pancreas on one side and the posterior abdominal wall on the other side intersect. The proximal part of the duodenum stands out from the periprocess. Visually and by palpation, the boundaries of the cicatricial and ulcerative process and its nature of the relationship with the pylorus 4 and the large duodenal papilla 5 are determined (Fig. 1). At the distal level of stenosis, transverse duodenotomy (A-B) is performed, which extends up the front wall to the proximal border of stenosis. Scar-altered walls of the duodenum are radically excised. The condition for using the method is the safety of the posterior and medial walls of the proximal part of the duodenum.

 The duodenal wound after radical excision of the scar walls of the tubular stenosis is represented by the transversely intersected anterolateral walls of the basal 6 and post-bulbar levels 7 while maintaining the continuity of the posterior wall 8 (Fig. 2). For plastic closure of the defect in the walls of the proximal section, the walls of the distal half of the duodenum can be used. If the lower horizontal branch of the duodenum 9 is mobile and is not fixed to the pancreas throughout, its removal from under the root of the mesentery of the small intestine significantly increases the upward mobility of the walls of the duodenum. For this, the ligament of Traits 10 completely intersects and the lower horizontal branch in the avascular zone is mobilized (Fig. 3). For surgery, only a slight longitudinal duodenotomy of the anterior wall of the vertical branch of the duodenum in the projection of the large duodenal papilla 11 is required (Fig. 3).

 Plastic surgery starts from the bottom, from the corners of the duodenal wound formed by the edge of the "bridge" and the edges of the lower transverse duodenotomy (Fig. 3, points 12, 13). Knotted seams, absorbable monofilament along the line of the "bridge" in the proximal direction on both sides adapt the side and then the front walls of the KDP. The walls of the distal duodenum that are “cleared” of scars are capable of significant dilatation, which often makes it possible to replace the duodenal defect without longitudinal duodenotomy, reaching the pyloric level. In the final version (Fig. 4), the suture line repeats the contour of the “bridge” of the posterior wall 14, 15 and the line of the proximal peri-pyloric duodenotomy 16. The suture line and the entire pancreatoduodenal complex are hidden by a mobilized lock of the omentum.

 After duodenoplasty, selective proximal vagotomy is performed: the cardia is reduced by 1.5 - 3 cm, the abdominal esophagus, cardia and lesser curvature are skeletonized from the angle of the stomach (above the point of entry of the first branch of the distal goose foot of the Letarget nerve).

 Areflux cardia is formed. To do this, the esophagus-cardiac transition is taken onto the holder, the angle of His is created by a suture that captures the bottom of the stomach, esophagus and the edge of the AML with the remains of the esophageal-diaphragmatic ligament. The esophageal-gastro-diaphragmatic ligaments are restored with three sutures, capturing with two of them the front wall of the bottom of the stomach, the paesophageal tissue and the left leg of the AML and one - the posterior wall of the bottom of the stomach and the left leg of the AML. The method of invagination creates an areflux esophagocardiogastric valve.

 The method was tested on 14 patients.

 Patient V., 46 years old, was admitted to the clinic of the Republican Center for Functional Surgical Gastroenterology on March 8, 1996, with a diagnosis of duodenal ulcer. Subcompensated stenosis. An ulcerative history since 1986 with annual seasonal exacerbations. Despite antacid treatment, in February 1996 he noted a deterioration. Upon receipt of a complaint of "hungry" and night pain in the epigastrium and right hypochondrium, repeated vomiting, weight loss of up to 6 kilograms. FGDS: the pylorus of the rounded shape is dilated, the function is preserved, the bulb, starting from the basal level, is stenosed to 0.6 cm, not passable by the endoscope. On the anterolateral wall in the stenosis zone, a partially visible crater-shaped ulcer is about 0.5 cm in size. The bottom is made of fibrin. X-ray: the stomach on an empty stomach contains a lot of fluid, the antrum is contrasted. The lower border of the stomach in an upright position at the level of the scallop line. The gatekeeper is dilated. The proximal border of stenosis is the basal level of the gastroduodenal transition. The extent of stenosis due to limited barium filling is not determined. After 1 hour, 2/3 of the barium in the stomach. Operated on 03/21/97. An intraoperative study revealed prolonged stenosis of the proximal part of the duodenum, shortening of the gastroduodenal transition. Intraduodenally revealed: ulcerative crater on the lateral wall in the post-bulbar level and cicatricial transformation of the anterior wall from the basal to post-bulbar levels. Resection of the modified walls of the duodenum is performed. The gatekeeper is preserved, distal portions of the upper sector are exposed. The large duodenal papilla is present to the line of resection (the total mouth is 0.5 cm distal). The length of the “bridge” of the posterior wall was 6 cm. 50.0 ml of a 0.5% solution of novocaine were introduced retroduodenally. The vertical and lower horizontal parts of the duodenum were mobilized with the preservation of the mesenteric vessels and the intersection of the ligament of the treitz. Replacing the extended defect of the anterior and lateral walls of the proximal part of the duodenum is performed by the dilated distal part of the duodenal lumen with a slight longitudinal duodenotomy of the anterior wall (1.5 cm).

 Plastic surgery began from below, from the corners of the duodenal wound formed by the edge of the "bridge" and the edges of the lower transverse duodenotomy. With knots, absorbable by monofilament along the “bridge” line in the proximal direction, the side and then the front walls of the KDP were adapted on both sides. Thus, the suture line repeated the contour of the “bridge” of the posterior wall and the line of the proximal peri-pyloric duodenotomy. The mobilized lock of the oil seal is covered with a line of seams.

 After duodenoplasty, a selective proximal vagotomy was performed: the cardia was reduced by 1.5 - 3 cm, the abdominal esophagus, cardia and lesser curvature were skeletonized from the angle of the stomach (above the point of entry of the first branch of the distal goose foot of the Letarget nerve). The areflux cardia is formed. The esophageal-gastro-diaphragmatic ligaments were restored.

 The postoperative period was uneventful. On the 3rd day, the nasogastric tube was removed, on the 5th day they were allowed to eat. Discharged from the hospital on the 10th day after the operation. Examined after 6 months. He did not make complaints during the examination, he did not follow a diet. When FGDS revealed moderate residual deformity of the duodenal bulb, there are no signs of reflux gastritis and reflux esophagitis. On R-graph: deformation of the proximal sections of the duodenum in the right lateral projection in the form of an anterior anterior angle of the vertical branch, the upper horizontal branch is moderately shortened. Duodenal bends are smoothed. The evacuation from the stomach is portioned, after 1 hour - 1/3 of barium in the stomach, after 1 hour 30 minutes - complete evacuation.

 1 year after the operation, he feels well, does not follow a diet, works in his specialty.

 Using the method allows to achieve the cure of duodenal ulcer. The high functionality of the proposed operation allows you to quickly restore full gastric digestion, provides portioned food advancement in the upper gastrointestinal tract, and prevents the development of reflux gastritis and post-vagotomy disorders. Thus, the application of the method leads to a quick and reliable recovery of patients, provides them with a high quality of life.

Claims (1)

 A method for the treatment of duodenal ulcer, including SPV and excision of the stenotic walls of the duodenum, characterized in that the continuity of the intramural innervation is preserved, and the extensive defect of the proximal half of the duodenum is closed by the displaced walls of its distal part, removed from the root of the mesentery of the small intestine.

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