RU2150892C1 - Method for treating bleeding duodenal wound in children - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing duodenectomy. Bleeding vessel is sutured. Two symmetric U-shaped flaps of opposite orientation are distally cut out on both sides of the ulcer wound. Flap width exceeds the ulcer size by 2-3 mm. Flap length is 2-2.5 cm. The flaps are successively sutured. First, the distal flap is placed on the ulcer. Free end is brought into coincidence with the proximate flap base. The distal flap is fixed on its perimeter with mucous and muscular layer caught. EFFECT: provided physiological conditions of operation in children. 2 dwg

Description

 The invention relates to medicine, in particular to pediatric surgery. Due to the fact that peptic ulcer of the stomach and duodenum (duodenal ulcer), complicated by penetration and bleeding, has become common in childhood.

 There is a method of treating bleeding duodenal ulcers by surgical intervention, including selective proximal vagotomy, duodenotomy of the upper and back walls of the duodenum, ulcer excision / A.C. 1009432, "Surgical method for the treatment of bleeding duodenal ulcers" M.kl. A 61 B 17/00, publ. 04/03/07. N 13 /.

 However, this method has significant drawbacks: trauma / almost complete intersection of the duodenum / and prolongation of the operation time / proximal, selective vagotomy / in a severe patient.

 Closest to the proposed method for the treatment of bleeding duodenal ulcers is another operation, the essence of which is that after hemostasis, the ulcers are covered with a wall of the intestine devoid of mucous membrane and complement the operation with gastroenteroanastomosis (A. S. 1.090.365, “A method for the treatment of a bleeding duodenal ulcer intestines ", M.cl. A 61 B 17/00, prior. 05.24.82, publ. 84.05.07 No. 17 /.

 However, this method is not physiologically sound enough in childhood, because it violates the normal ratio of organs in a growing body and the natural passage through the gastrointestinal tract.

 The objective of this proposal is to develop a new operation that is safer and physiological in childhood.

 The task is achieved as follows: the cover is carried out by the fact that on the both sides of the ulcer, two symmetrical oppositely oriented U-shaped flaps are proximally and distally cut from the mucosa, the width of which exceeds the size of the ulcer by 2-3 mm, and the length is 2-2.5 cm. Successive sewing of the flaps is carried out, while first the distal flap is placed on the ulcer so that its free end is combined with the base of the raised proximal flap, fixing along the perimeter with the capture of the mucous and muscular loya. Then, the proximal flap completely overlaps the hemmed distal flap and is sewn along the perimeter with the capture of the mucous and muscle layer.

The proposed operation scheme has the following advantages:
1. Two flaps from the mucosa of the small intestine are the body’s own tissue, which leads to their good survival and excludes the development of allergic reactions.

 2. The size of the flaps allows you to completely cover the ulcer defect without any technical difficulties.

 3. The procedure for sewing flaps, the capture of the mucous membrane and muscle layer provide complete cover for a ulcerative defect.

 This method of treating a penetrating bleeding duodenal ulcer restores the continuity of the duodenal mucosa and eliminates the effect of the acid-peptic factor on the pathological focus. Unlike the prototype, the method is applicable in childhood, because natural anatomical and physiological conditions are preserved for the normal digestion process, which is important for a young growing organism.

The invention is illustrated in the drawing, where in FIG. N 1 shows a diagram of the operation:
а / stage of cutting out mucous flaps;
b / stage stitching of mucous flaps.

 The method is as follows: after performing fibroesophagogastroduodenoscopy / FEGDS /, detecting bleeding ulcers of the duodenum, with the ineffectiveness of intensive hemostatic therapy, surgery is performed - median laparotomy, duodenotomy, flashing of a bleeding vessel with a nodal or Z-shaped suture. Then carry out its cover. On both sides of the ulcer, two symmetrical, opposed U-shaped flaps are proximally and distally cut out from the intestinal mucosa, which will be fixed with an overlap to each other. The width of the flaps should exceed the size of the ulcer by 2-3 mm up and down. The length of the flaps is 2-2.5 cm. After cutting, the flaps are sequentially sewn: first, one flap, distal, is placed on the ulcer so that the end of this flap approaches the base of the raised proximal maximally and fix it with single interrupted sutures along the perimeter with the capture of the mucous and muscle layer. Then they take the opposite, proximal flap and cover the previous one with its complete overlap, and sew it with nodal sutures along the perimeter of the flaps with the capture of not only the mucous, but also the muscle layer. Thus, the ulcer is covered with mucous flaps. A similar operation is used in a children's clinic. Long-term results are traced over a number of years. No complaints were filed. During the period of observation of exacerbation of duodenal ulcer, neither clinically, nor radiologically, nor on FEGDS.

 Clinical example: Patient P., 1.5 years old, was admitted to the pediatric surgery clinic of the Novokuznetsk GIDUV with a diagnosis of right-sided destructive pneumonia, pyopneumothorax on the right. After drainage of the pleural cavity, active aspiration and antibiotic therapy are started. The patient's condition improved within a week. On the 8th day, the patient revealed profuse bleeding / scarlet blood with clots from the anus /. Intensive hemostatic therapy was performed. The bleeding stopped. On the 3rd day, bleeding again, similar to the previous one. Laparotomy performed. An audit of the abdominal cavity revealed the presence of blood in the terminal part of the small intestine and in the large intestine. No other pathology was detected. Due to the absence of the most common causes of intestinal bleeding in children / hemangioma, Meckel diverticulum, lack of bloody vomiting, dilated veins of the esophagus /, the stomach and duodenum were revised. After dissection of the gastrocolic ligament, visually on the posterior wall of the stomach from the cardia to the pyloric department, no pathology was detected. During the audit of the initial and descending department of the duodenum, a kallic ulcer of the duodenum was revealed. Duodenotomy performed. An ulcer with callous edges was located on the back wall of the duodenum, in the center of which a bleeding vessel was found. Given the severity of the underlying disease / pleural empyema, pyopneumothorax, the presence of ongoing bleeding and the nature of the ulcer /, with the aim of radical hemostasis, it was decided to perform the following operation.

 The bleeding vessel was flashed with a Z-seam. After that, on both sides of the ulcer, two symmetrical U-shaped flaps were cut proximally and distally from the intestinal mucosa, the width of the ulcer exceeding the size of the ulcer by 2-3 mm up and down. The flap length is 2 cm. The proximal flap is raised, the distal flap is laid on the ulcer to the base of the proximal and fixed with interrupted sutures around the perimeter. The proximal was laid on top and fixed around the perimeter with single interrupted sutures with the capture of the mucous and muscle layers of the intestine.

 The postoperative course is favorable. Feeding started from the 7th day. After 40 days to cure the underlying disease, he was discharged home in satisfactory condition. Observed at the dispensary, bleeding, exacerbation of peptic ulcer is not noted. On FEGDS, radiography of the stomach and duodenum, no pathology was detected.

Claims (1)

 A method of treating a bleeding duodenal ulcer in children, which consists in performing a laparotomy, duodenotomy, flashing a bleeding vessel, characterized in that on the both sides of the ulcer, two symmetrically opposed U-shaped flaps are cut proximally and distally from the mucosa, the width of which exceeds the size of the ulcer by 2 - 3 mm and a length of 2 - 2.5 cm, successive sewing of the flaps is carried out, while first the distal flap is placed on the ulcer in such a way that its free end is combined with the base of the raised proximal flap, fixing along the perimeter with the capture of the mucous and muscle layers, then the proximal flap completely overlaps the hemmed distal flap and is sewn along the perimeter with the capture of the mucous and muscle layers.