RU2145191C1 - Surgical method for treating peripapillary ulcers of the duodenum - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves mobilizing duodenum walls in ulcer zone. A part of duodenum wall is excised. Major duodenal papilla is implanted into the corner of duodenal stump beginning from the inferior boundary of the stump. Both walls of the duodenum and papilla ampulla are caught into the suture. Interrupted sutures are put in along the major duodenal papilla perimeter. Pacreatoduodenostomy is carried out. U-shaped sutures are put in along the perimeter of the ulcer crater adjacent to the inferior boundary of the stump and its non-sutured part. The sutures are put to enable pancreatic juice discharge through the minor duodenal papilla into non-sutured part of duodenal stump to take place. Gastroduodenectomy is carried out. EFFECT: provided normal bile and pancreatic juice passage. 4 dwg

Description

 The invention relates to medicine, namely to the surgical treatment of periapical, duodenal, "giant" ulcers.

There is a method of restoring the common bile and Wirsung ducts during their accidental damage during surgery, including transpapillary-transduodenal duct drainage, in which the duodenum is crossed at the level of the upper edge of the pancreatic head and the latter is invaded into the lumen of the duodenum by applying double-row serous-serous the wall and peritoneal cover of the pancreas with the capture of part of the hepatoduodenal ligament
/cm. a. from. USSR N 1558395, MKI ⁵ A 61 B 17/00, publ. 04/23/90, Bull. N 15 /.

 A known method of treating the common bile and Wirsung duct provides restoration of their functions impaired by the operation, but is not applicable to restore the functions of the large duodenal papilla and small duodenal papilla when they are in the ulcer crater.

The closest solution to the technical nature and the achieved effect, taken as a prototype, is a method for surgical treatment of complicated periapical duodenal ulcers, including resection of a segment of the intestine involved in the ulcer process, mobilization of the posterior wall of the distal end, bypassing the site of the large duodenal papilla. Then the posterior wall of the intestine from the papilla is sutured in the longitudinal direction for 1.2 - 2.0 cm and a duodenal anastomosis is applied end to end
/cm. a. from. USSR N 1674812, MKI ⁵ A 61 B 17/10, publ. 09/07/91, Bull. N 33 /.

 The known method allows you to perform radical operations for the surgical treatment of duodenal ulcers if the large duodenal papilla is located on the lower edge of the ulcer, but it is not applicable if the large duodenal papilla and the proximal small duodenal papilla, in which the opened santorin duct is sometimes involved, are involved performs the function of the Wirsung duct, which requires the preservation of its function in order to avoid postoperative pancreatitis during its ligation.

 The basis of the invention is the task to develop a method for the surgical treatment of periapical ulcers of the duodenum, when the large duodenal and small duodenal papilla are located directly in the crater of the “giant” ulcer, by implanting a large duodenal papilla in the corner of the stump of the duodenum, and the non-stitched portion of the stump and excess of its lower wall use for applying pancreatoduodenostomy. This allows you to operate "giant" ulcers when large and small duodenal papillae are involved in the ulcer process, preserve their functions, prevent stenosis and ensure normal passage of bile and pancreatic juice.

 This object is achieved in that in a method for the surgical treatment of peri-duodenal ulcers of the duodenum, including mobilization of the walls of the duodenum in the ulcer area, resection of a portion of the wall of the duodenum, according to the invention, implantation of the large duodenal papilla into the angle of the stump of the duodenum, and starting from the capture of the duodenum, and a seam both the walls of the duodenum and the ampoule of the large duodenal papilla, impose nodal sutures along the perimeter of the papilla, where the last suture The appropriate first and then carry pankreatoduodenostomiyu while superposed U-shaped perimeter seams ulcer crater with the lower edge of the stump and its unsutured to provide a part of the outflow of pancreatic juice through a small duodenal papilla in unsutured stump part of the duodenum, and then carried gastroduodenal resection.

 The proposed method allows you to almost completely remove the ulcer crater beyond the lumen of the duodenum, leaving an unheated part of the stump and an excess of its lower wall to be used for applying pancreatoduodenostomy. This makes it possible to preserve the large and small duodenal papillae, prevent their stenosis and ensure normal passage of bile and pancreatic juice.

 A search conducted by the sources of scientific, medical and patent information showed that the totality of all the essential features of the proposed solution is not known, therefore, the proposed solution meets the requirement of novelty, i.e. it is not known from the prior art.

 As a result of the search, in the known solutions, no combination of distinctive features was found allowing radical treatment of duodenal ulcer (giant ulcer, more than 2 cm in diameter) when the large duodenal papilla and small duodenal papilla are in the ulcer crater, save large duodenal papilla, its function and the function of the small duodenal papilla, to avoid their stenosis. Thus, the claimed solution meets the requirement of "inventive step".

The proposed method is illustrated by schemes, where:
in FIG. Figure 1 shows the crater of a "giant" ulcer with a large duodenal papilla, proximal to which the small duodenal papilla and the descending part of the duodenum are located;
in FIG. 2 is a diagram of the implantation of a large duodenal papilla into the angle of the stump of the duodenum;
in FIG. 3 is a diagram of pancreatoduodenostomy by applying U-shaped sutures along the perimeter of the ulcer crater and the walls of the duodenum;
in FIG. 4 is a view from the side of the lumen of the stump of the duodenum, which shows the sewn large duodenal papilla and small duodenal papilla with a santorinium duct opening in it.

 The diagrams show the procedure of operation, where a pancreatic gland 1 contains a crater of a “giant” ulcer 2 with a large duodenal papilla 3 and a small duodenal papilla 4 located directly in the crater of an ulcer 2, and the mobilized descending part of the duodenum 5 (Fig. 1).

 Nodal sutures 6 are applied along the perimeter of the papilla 3 with the capture of the walls of the duodenum 5 and ampoules of the papilla 3 (Fig. 2).

 U-shaped sutures 7 impose on the ulcer crater 2 of the pancreas 1 and on the walls of the duodenum 5 (Fig. 3). In the lumen of the stump of the duodenum 5 there is a large duodenal papilla 3, sewn into the lower corner of the stump, and a small duodenal papilla 4 with a Santorinium duct 8 opening in it.

 The method is as follows.

 An upper median laparotomy is performed with the installation of a retractor MZ Sigal. A revision of the abdominal cavity is carried out and the presence of peptic ulcer, periprocess, peptic ulcer deformation of the duodenum confirm the diagnosis of peptic ulcer of the duodenum and tentatively establish the localization of the ulcer. In the area of the duodenal bulb, scar-adhesion layers are dissected, the anterior and lateral walls of the duodenum are mobilized 5. The greater and lesser curvatures of the stomach are also mobilized, after which the ulcer crater is opened along the posterior wall of the duodenum. The ulcer crater 2 on the pancreas is inspected 1. The presence of a large duodenal papilla 3 and a small duodenal papilla 4 is determined in crater 2 (Fig. 1). Visually and instrumentally, a large duodenal papilla is inspected for the location and location of the Wirsung duct 8.

 Cicatricial tissues were dissected on the duodenum 5 and the posterior wall of the duodenum was mobilized 0.5 cm distal to the ulcer crater 2. An ulcer crater 2 was treated with an antiseptic solution. Then carry out the implantation of a large duodenal papilla 3 (Fig. 2), starting from the lower edge. In the first nodal suture 6 capture both walls of the duodenum 5 and the ampoule of the papilla 3. The ligature is knotted outward. Next, impose nodal sutures 6 around the perimeter of the papilla 3 with the capture of the serous-muscular layer of the intestinal wall 5 and the ampoule of the large duodenal papilla 3 at a distance of 2 mm from each other. Threads are cut in stages, using each previous in the form of holders. The last seam is imposed like the first, i.e. with the capture of both walls of the intestine 5 and ampoule papilla 3 (Fig. 2). When the “cuff” of the mucosa is involved in the ulcer process, a papillosphincterotomy is performed on the large duodenal papilla.

 The next stage is the formation of pancreatoduodenostomy (Fig. 3).

 U-shaped sutures 7 are placed on the lower wall of the duodenal stump 5 and its non-dried part of the duodenum 7, with an ulcer 2 located on the pancreas 1 being taken along the perimeter of the crater, with the possibility of providing an outflow of pancreatic juice through the small duodenal papilla to the non-intestinal stump.

 Then produce gastroduodenal resection with the imposition of a gastrointestinal anastomosis and drainage of the extrahepatic bile ducts.

 Example. Patient K., 39 years old, was hospitalized in the surgical department of the city hospital on 2.10.93 in urgent order with the presence of pronounced pain in the epigastric region. Duodenal ulcer suffers for more than 10 years. Repeatedly treated in the therapeutic and surgical hospitals of the city and regional hospitals. I categorically refused the operation. The last time he received antiulcer therapy in the gastroenterological department of the city hospital in August 1993, the Department examined. With fibrogastroduodenoscopy, a sharply deformed duodenal bulb was found, the ulcer crater occupying half the perimeter of it. 11.10.93, in a planned manner operated. During the operation, a powerful ulcerative infiltrate of 8x7 cm was found in the area of the duodenal bulb with the involvement of the head of the pancreas, gall bladder, transverse colon, large and small omentum. When the infiltrate was destroyed, an ulcer crater with a diameter of more than 4 cm was opened. A large duodenal papilla was found in the ulcer crater and a 2 cm small duodenal papilla above which transparent pancreatic juice was supplied. The ulcer crater is treated with furatsillin solution. An implantation of a large duodenal papilla into the angle of the duodenal stump was performed. In connection with the deformation of the small duodenal papilla, transpapillary drainage of the Santorinia duct was performed on the hidden drainage. U-shaped sutures along the perimeter of the ulcer crater imposed pancreatoduodenostomy. In order to prevent the failure of the duodenal stump, the extrahepatic bile ducts were drained by microcholecystomy. A gastroduodenal resection was performed with 2/3 of the stomach removed and the gastrointestinal anastomosis superimposed on a short loop according to B-P in the Hofmeister-Finsterer modification. The postoperative course is smooth. On the 12th day, the microcholecystostomy was removed, which closed independently after two days. Discharged in satisfactory condition on the 16th day after surgery. Examined after 4 months. He has no complaints; he works as a teacher. On the control gastroscopy - gastritis of the operated stomach.

 The proposed method was applied in four patients, in two patients, due to cicatricial deformity of the small duodenal papilla, transpapillary drainage of the Santorinia duct was performed on the hidden drainage and in one patient, papillosphincterotomy. In order to prevent postoperative pancreatitis and insolvency of the duodenal stump, all four patients underwent drainage of extrahepatic bile ducts / through choledochostomy or microcholecystostomy /.

 Using this method, no complications were observed. In the distant postoperative period, signs of pancreatitis, cholangitis in patients were not found.

Claims (1)

 A method for surgical treatment of periapical duodenal ulcers, including mobilization of the walls of the duodenum in the ulcer area, resection of a portion of the wall of the duodenum, characterized in that implantation of the large duodenal papilla is performed at the angle of the duodenal stump, starting from the lower edge of the duodenum and capturing and the ampoule of the large duodenal papilla, impose nodal sutures along its perimeter, where the last suture corresponds to the first, after which p an ankreatatoduodenostomy, with U-shaped sutures along the perimeter of the ulcer crater with the lower edge of the stump and its inaccessible part, with the possibility of providing an outflow of pancreatic juice through the small duodenal papilla to the unheated part of the duodenal stump, then gastroduodenal resection is performed.

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