RU2157661C2 - Surgical method for treating bleeding postbulbar duodenal peptic ulcer penetrating common bile duct wall - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves bringing ulcers beyond the duodenum lumen. Choledochus protection is carried out by fixing vascularized flap of anteroexterior duodenum wall on the ulcer defect boundary. The flap is formed in the course of extraduodenal ulcer transportation. The distal and proximal ends of the duodenum are mobilized. Duodenoduodenal anastomosis is created. EFFECT: enhanced effectiveness of treatment. 2 dwg

Description

 The present invention relates to medicine, namely to surgery, and can be used in the treatment of bleeding postbulbar ulcers penetrating into the common bile duct.

 Surgical treatment of bleeding duodenal ulcers, especially glaucoma localization, remains an important section of surgical gastroenterology. The literature data indicate an increased risk of bleeding from postbulbar ulcers, requiring more active surgical tactics than with duodenal ulcers [1]. The technical difficulties of surgical intervention for bleeding postbulbar ulcers, in addition to their low location, are due to a number of features, in particular, in a significant number of cases (16%), the ulcer is located directly above the large duodenal papilla, penetrating into the hepatoduodenal ligament with the formation of choledocho-duodenal fistula or without it [2].

 There is a method of treating bleeding postbulbar ulcers penetrating into the wall of the common bile duct, which consists in excising the ulcer together with a section of the posterior wall of the duodenum and choledoch wall in the process of performing radical duodenoplasty with the subsequent formation of suprarenal choledocho-duodenoanastomosis [3]. The operation involves reliable hemostasis and ensures the passage of bile in the duodenum during the formation of distal stricture of the common bile duct. The disadvantages of the analogue include a violation of the anatomical and functional connections and the form of a high and wide choledocho-duodenal anastomosis, which can lead to reflux of the duodenal contents into the common bile duct and the development of reflux cholangig resistant to conservative treatment.

 There is also a method of treating bleeding postbulbar ulcers with penetration into the common bile duct, consisting in the excision of the ulcer with the formation of the term lateral choledochoduodenostomy or choledochojejunoanastomosis [2]. The disadvantages of this method include a high risk of failure of the joints of the anastomosis. In addition, the use of this method significantly complicates and lengthens the operation, which in an urgent situation is not indifferent to the anemized patient.

 For the prototype, we adopted the method [4], which consists in subpiloric segmental resection with extraduodenization of the ulcer crater in combination with selective proximal vagotomy.

 Excretion of an ulcerative crater beyond the lumen has an undoubted positive effect of the operation, but with penetration of an ulcer into the common bile duct, the formation of an extended stricture of the latter is very likely. In addition, the abandonment of a bleeding ulcerative crater is unsafe with respect to a possible recurrence of bleeding into the free abdominal cavity and bile leakage when penetrating to the mucous membrane of the common bile duct or unhealthy choledochoduodenal fistula.

 The aim of the proposed method is to improve the immediate and long-term results of surgical treatment of bleeding postbulbar duodenal ulcers penetrating into the wall of the common bile duct.

 The objectives of the invention is a reliable stop of bleeding in the shortest possible time with minimal surgical trauma for the patient and cure for peptic ulcer.

 In the clinic, we have developed a method for the surgical treatment of bleeding postbulbar ulcers with penetration into the wall of the common bile duct, including removing the ulcer crater beyond the duodenal lumen, characterized in that the protection or plastic replacement of the choledoch wall defect is carried out by forming a flap of the anterior-outer wall of the duodenum and its subsequent fixation to the edges of the defect of the common bile duct.

 For a better understanding of the essence of the operation, see FIG. 1 and 2, which schematically depict: 1 - ulcerative crater with a defect in the wall of the common bile duct; 2 - flap of the front-outer wall of the duodenum; 3 - a large duodenal papilla; 4 - distal and proximal ends of the duodenum; 5 - marginal transverse vessels feeding the flap.

 The method is as follows: after an external revision of the duodenum 12, a transverse postbulbar duodenotomy is performed to clarify the localization of the ulcer from the side of the intestinal lumen. Under the control of vision, scarred tissues are excised with the elimination of cicatricial deformities and cutting out a flap of the anteroposterior wall of the duodenum 12 congruent to the ulcerous crater or defect of the common bile duct, without crossing its transverse marginal vessels 5 and without separating it from the outer semicircle of the ulcerous crater.

 The cicatricial edges of the internal semicircle of the ulcerative crater are economically excised. The formed flap 2 is carefully adapted to the ulcerative crater or to the defect of the choledoch wall 1, then it is hemmed along the perimeter with single-row atraumatic interrupted sutures using the precision technique. The distal and proximal ends of the duodenum 4 are mobilized with the formation of duodeno-duodenoanastomosis with single-row interrupted sutures. Subsequently, selective proximal vagotomy is performed. In all cases, biliary tract decompression was performed in the form of microcholecystostomy or drainage of the common bile duct. In the presence of cicatricial changes in the large duodenal papilla, the operation was supplemented with papillosphincterotomy.

 According to the specified method, 13 patients with bleeding postbulbar ulcers with penetration into the bile duct wall were operated on. In 2 cases, there was postoperative pancreatitis, stopped by conservative measures. There were no other complications associated with the operation technique. Relapses of bleeding, which were observed in 8.7% of cases after leaving a postbulbar ulcer, were not observed at all.

 Example: Patient K., case history No. 988, was admitted to the 2nd ECHO BSMP on 12.02.95 with a diagnosis of duodenal ulcer complicated by bleeding. Gastroduodenoscopy revealed a postbulbar ulcer of the posterior-lateral wall of the duodenum, covered by a red thrombus, from which blood leaked. Er-1.9 t / l, HB-56 g / l. 02/12/95 the patient was operated on an emergency basis. After transverse duodenotomy, the duodenum was crossed transversely to the ulcer crater with excision of the scarred tissues and cutting out the flap of the anterior-outer wall measuring 1.5-1.3 cm. The vessels supplying the flap did not intersect. Without separating the flap from the external anterior semicircle of the ulcer crater, careful adaptation and hemming of the flap to the ulcer crater were made. Control of hemostasis and gallstasis. The proximal and distal sections of the duodenum are economically mobilized with the formation of duodeno-duodenoanastonosis "end to end", single-row interrupted sutures. Microcholecystostomy throughout. Selective proximal vagotomy. Abdominal drainage and wound closure.

 The postoperative period was uneventful. Discharged 12 days after surgery. Examined after 1 year. There were no signs of violation of the passage of bile.

 Thus, the proposed method allows to improve the immediate and long-term results of the treatment of patients with bleeding penetrating postbulbar ulcers.

Literature
1. A.A. Kurygin, V.V. Toidze, V.V. Rumyantsev, V.N. Baranchuk Surgical treatment of duodenal ulcerous ulcers complicated by bleeding. - Surgery. 1988. - N. 5. - p. 36 - 39.

 2. A. A. Kurygin, V.V. Rumyantsev Vagotomy in surgical gastroenterology // - St. Petersburg: Hippocrates. - S. 147.

 3. V.I. Onopriev. Sketches of functional surgery of peptic ulcer. // - Krasnodar. 1995.- S. 205.

 4. Helwing L., Heymann H. Postpylorische resection des kimplizierten ulkus der duodenal - hinterwand im rahmen fonn - und fuktionsgerechter magenchinitgie // Chirurg. 1978- Bd. 49 - N. 1. - S. 29 - 32.

Claims (1)

 A method for the surgical treatment of a bleeding postbulbar duodenal ulcer with penetration into the wall of the common bile duct, comprising removing the ulcer from the intestinal lumen, characterized in that the plastic and patching of the choledochus wall are carried out by fixing to the edges of the ulcer crater a vascularized flap of the anterior-outer wall of the duodenum the process of extraduodenization of the ulcer, after which the distal and proximal ends mobilized after duodenotomy are mobilized and form duodenodes odenoanastomoz.

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