RU2174369C2 - Method for treating the cases of duodenal peptic ulcer - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out anterior transverse rhomboid duodenotomy for 2/3 parts. Cicatricial adhesions are removed from the anterior duodenum wall. Pathologic focus on the posterior duodenum wall is excised in duodenal direction. Then tunnel mobilization is carried out of one of the halves of the posterior duodenum wall. Posterior duodeno-omentopexy to contralateral wall and at the level of the middle of ulcer bed is carried out. Anterior duodenum wall is sutured in the transverse direction and completed with anterior duodeno-omentopexy. EFFECT: reduced risk of post- and intraoperative complications. 7 dwg

Description

 The invention relates to medicine, namely to surgical gastroenterology, and can be used to treat complicated ulcers of the posterior wall of the duodenum.

 There is a method of treating peptic ulcer with localization of an ulcer on the posterior wall of the duodenum, when terminal vessels are tied along the greater and lesser curvature of the bulb, the right gastric artery, a segment of the duodenum with an ulcer is excised, the intestinal stump is sutured, and one gastroduodenoanastomosis is applied. When the ulcer is localized on the posterior upper (or posterior lower) wall of the bulb, the duodenal bulb segment is mobilized with the right gastric artery ligation, the mobilized posterior wall of the duodenum is removed on the holders, part of the intestine with the ulcer is excised in the transverse direction, and the anterior transverse sutures are superimposed on the front and left sutures (V.T. Zaitsev and N.N. Veligotsky. Surgery, 1985, N 2, p. 34 - 37). These options for the removal of a duodenal ulcer are accompanied by significant circulatory disorders, bowel innervation, loss of pyloric sphincter function and a violation of the continuity of the gastroduodenal transition.

 The closest are methods of treating duodenal ulcer by means of segmental radical duodenoplasty with excision of periduodenal scars, melting of intestinal deformity, excision of the entire intestinal segment with an ulcer, end-to-end intestinal anastomosis, and the second method - bridging radical duodenoplasty, including bridge duodenoplasty, including the walls of the intestine, one of the options for excising ulcers while keeping intact one or two sections of the intestinal wall, last blowing suturing wall transversely intestine. The operation is supplemented by antacid intervention on the stomach (Author's certificate N 971286, VI Onopriev and Yu.T. Zamulin. VI Onopriev. Etudes of functional surgery of peptic ulcer. Krasnodar, 1995). However, with these methods, complications arise associated with a significant extent of the removed part of the intestine, trauma to the pancreas, circulatory disturbance, intestinal innervation, and, consequently, the function of the gastro-duodenal segment.

 With bridge-like duodenoplasty, circulatory disorders, innervation, and function are also significant, as part of the parietal vessels is ligated, a significant part of the duodenum is mobilized. Postoperative pancreatitis, pancreatic necrosis, impaired motor function and passage along the duodenum occur, relapse ulcers, insolvency and stenosis are possible.

 The objective of the invention is the prevention of postoperative complications, pancreatitis, circulatory disorders, innervation, motor-evacuation function of the duodenum.

 The task is achieved by the fact that anterior transverse rhomboid-shaped 2/3 duodenotomy, anterior duodenolysis, excision of the pathological focus of the posterior wall in the longitudinal direction, posterior duodenolysis with constant visual and palpation control of the treated tissues, then tunnel mobilization of one of the halves of the posterior intestinal wall is performed, posterior duodenomentopexy to the contralateral wall and at the level of the middle of the ulcer bed is performed, suturing of the posterior wall of the intestine is performed in the longitudinal direction Precision occurrence using microsurgical techniques, the front wall and sutured intestine, but in the transverse direction, suturing supplemented front omentoduodenopeksiey after duodenoplasty operation is performed on the stomach antacid.

 Comparative analysis with prototypes allows us to recognize that this technical solution meets the criterion of "novelty."

 When comparing the claimed solution not only with prototypes, but also with other technical solutions, no solution was found that has similar characteristics, which allows us to conclude that this technical solution meets the criterion of "significant differences".

 The invention is illustrated in FIG. 1 - 7.

 In FIG. 1. The anterior transverse rhomboid duodenotomy is depicted.

 In FIG. 2. The beginning of excision of the cicatricial ulcer of the posterior intestinal wall is shown.

 In FIG. 3. presents the final stage of excision of the cicatricial ulcer of the posterior wall of the intestine.

 In FIG. 4. The scheme of mobilization of one of the halves of the posterior wall of the duodenum is demonstrated.

 In FIG. 5. The posterior omentoduodenopexy and tamponade of the ulcerous crater are presented, fixation of the omentum at the entrance to the retroduodenal tunnel.

 In FIG. 6. shows the technique of suturing the posterior wall of the duodenum.

 In FIG. 7. Demonstrates the technique of suturing the anterior wall of the duodenum.

 The method is as follows.

 After partial isolation from the scars of the anterior wall of the duodenum, the anterior transverse rhomboid duodenotomy is performed at 2/3 of the diameter of the intestine (Fig. 1). A visual and digital audit of the duodenum, pyloric ulcer, and ulcer are performed. If necessary, duodenolysis of the intestinal walls is made on the finger inserted into its lumen. This technique accelerates and increases the reliability, non-invasiveness of the allocation of the front, upper and lower walls of the intestine, ensuring greater safety of blood supply and innervation of the intestine. After the expander is introduced into the wound of the intestine, isolation of the intestinal section with the ulcer from the proximal and distal sections of the gastrointestinal tract, the posterior wall of the intestine and ulcer are revised.

 With a bleeding ulcer, the vessel in the ulcer is stitched, and then, as in the case of penetrating and ulcers with limited cicatricial deformation, longitudinal sections of the intestine bordering the ulcer are made. Incisions are made within unchanged sections of the intestine (up to 1 cm from the edge of the ulcer) with a scalpel to the serous layer or prepancreatic tissue (Fig. 2). Then the scar-ulcerative lesion is excised with scissors (Fig. 3). In the presence of subcompensated ulcerative stenosis, the primary cicatricial spur is additionally excised in the direction perpendicular to the axis of the intestine and the ulcer excision zone.

 To facilitate suturing of the posterior intestinal wall, a tunnel mobilization of a narrower half of the posterior intestinal wall in the layer of prepancreatic fiber is performed. For the convenience of mobilization, entwining ligatures are placed on the edges of the bowel defect, and the peritoneum at the edge of the intestine (on the small or large omentum) is dissected on the side and within the limits of the planned mobilization. Dull and sharp way mobilize one of the halves of the back wall of the intestine. With a high density of the location of the terminal parietal vessels 1 - 2 of them can be ligated and crossed to summarize the locks of the greater omentum on the feeding leg (Fig. 4). A lock of omentum is inserted into the tunnel formed behind the posterior wall of the intestine and fixed to the contralateral wall, mobilized over a limited length of the intestine, to its serous cover with three interrupted sutures. The second level of fixation of the omentum lock is the middle of the ulcer crater and its edge at the same level (Fig. 5). Sutures on the posterior wall of the duodenum are applied taking into account the precision microsurgical technique. The serous-muscular-submucosal layers of the posterior intestinal wall are stitched with separate sutures with monofilament thread N 4-00. The superimposed holders and ligatures of the edges of the posterior intestinal wall are reduced, the ligatures are fixed in this position with an elastic clamp and are tied in turn from the submucosal layer (Fig. 6). If a cicatricial spur was excised on the posterior side of the intestinal wall, it is first sutured in the transverse direction, and then the main wound is sutured longitudinally. The wound of the anterior intestinal wall is sutured in the transverse direction by serous-muscular-submucosal interrupted sutures (Fig. 7). Suturing of the diamond-shaped transverse duodenotomy by 2/3 of the diameter of the intestine in the transverse direction provides an increase in the perimeter of the intestine. Anterior omentoduodenopexy is performed. The operation ends with antacid intervention on the stomach.

 An example of experimental execution.

 Studies on the gastrointestinal complex of 10 human corpses and 20 studies on sexually mature dogs weighing 7-12 kg.

 Dog Bug, 8 kg. Under hexenal anesthesia, an upper-median laparotomy was performed, an anterior transverse rhomboid duodenotomy was performed in the bulb area by 2/3 of the intestinal diameter. An expander was introduced into the wound of the anterior wall of the bulb. The pyloric canal and the post-clavicular duodenum are isolated with tampons. Diathermocoagulation of the posterior bulb wall with a diameter of 0.5 cm was carried out. Two bordering incisions were made in the longitudinal direction with a scalpel. The scissors fragment of the posterior wall is excised to prepancreatic tissue. Hemostasis during the operation. On the edges of the wounds of the posterior wall of the intestine four entwined ligatures-holders are applied. The peritoneum was dissected at the upper edge of the intestine (without ligation and dissection of the vessels of the small omentum) within slightly larger than the size of the excision of the posterior wall of the intestine. In a blunt and sharp way, tunnel mobilization of half of the posterior bulb wall from the small omentum and partially of the second edge of the posterior bulb wall was carried out. A small gland perpendicular to the bulb is dissected over 4 cm and a strand of a large gland corresponding to the width of the tunnel is inserted into the formed tunnel behind the back wall of the bulb. A lock is sewn with three interrupted sutures to the serous cover of the posterior contralateral wall of the bulb and at the level of the middle of the excision of the posterior wall of the bulb with three sutures.

 Submucosal-muscular-serous nodal sutures were imposed without tying on the posterior wall of the bulb. Ligatures-holders and provisionally superimposed sutures brought together the edges of the posterior wall of the intestine. Holding ligatures are diverted to the sides, and a clip with elastic lips is applied to the provisional sutures near the intestine. The holders are removed, and the provisional sutures from the clamp are alternately removed and tied from the side of the submucosal layer. Atraumatic suture material N 4-00 was used. A lock of a large omentum is fixed with two interrupted sutures at the place of its entrance to the tunnel behind the duodenal bulb to the edges of the peritoneum of the dissected omentum. The wound of the anterior wall of the bulb is sutured in the transverse direction by serous-muscular-submucosal sutures according to the same technology as the posterior wall, but with nodes outward. The base of the lock of the greater omentum, used for posterior duodenomentopexy, is sutured with interrupted sutures to the anterior wall of the bulb in the transverse direction on both sides of the sutured intestinal wound. Studies on human corpses and on experimental animals have shown the technical feasibility of performing a radical-economical version of duodenoplasty for ulcers of the posterior wall of the duodenum. Morphological studies of the suture line of the anterior and posterior walls of the duodenum showed their healing by primary tension; there was an interposition of a large omentum between the posterior wall of the duodenum and the pancreas. There were no cases of inconsistency of the stitches, stenosis, development of pancreatitis and pancreatic necrosis, and the continuity of the gastro-duodenal transition was less affected.

 An example of clinical performance.

 Patient N., 46 years old, medical history 614/165, was admitted to the clinic 02/06/97, with a diagnosis of acute gastrointestinal bleeding of the II degree. Peptic ulcer of the duodenum suffers for three years. Upon receipt, fibrogastroduodenoscopy was performed. A chronic ulcer of the stomach angle of 30 x 20 mm about a thrombus and an ulcer of the anterior wall of the bulb 3 x 4 mm were found. Hemostatic and replacement therapy was performed. 02/08/97, the bleeding resumed and the patient, according to emergency indications, was operated at the height of the bleeding. An upper midline laparotomy was performed. An audit of the stomach and duodenum revealed an ulcer of the angle of the stomach, cicatricial deformity of the anterior wall of the duodenal bulb. Produced longitudinal gastrotomy in the antrum of the stomach. A revision of a stomach ulcer revealed a lack of bleeding in it. Blood comes from the duodenum. A transverse rhomboid duodenotomy was performed on 2/3 of the diameter of the intestine with excision of scars and ulcers. On the back of the bulb is a bleeding ulcer of 5 x 4 mm. Diathermocoagulation of a vessel in an ulcer. A section of the posterior intestinal wall with an ulcer is longitudinally excised. The upper half of the bulb is mobilized within the excised area. Posterior bulbomentopexy. Nodal sutures longitudinally sutured the posterior wall of the intestine. Nodal seams are imposed on the front wall in the transverse direction. Anterior bulbomentopexy. The stomach was mobilized by large and small curvature in 2/3 of the volume while maintaining the blood supply to the pylorus. The stomach is crossed over the pyloric sphincter and in the proximal part. An anastomosis according to Billroth - I was laid between the proximal stump of the stomach and the pyloric sphincter with two rows of nodal sutures. The postoperative period was uneventful. 02/20/97, in satisfactory condition, the patient was discharged for outpatient treatment. Two months later, he began to work as a driver. FGDS and X-ray studies after 3 and 6 months showed good function of the pylorus, portability of the evacuation of contrast and passage through the duodenum. A persistent decrease in acid-producing function was noted. He gained 5 kg in weight. Diet practically does not follow.

 Thus, the task is solved by reducing the number and severity of postoperative complications, improving the morphological and functional results of the proposed intervention in the early and long-term postoperative periods.

Claims (1)

 A method for surgical treatment of complicated forms of duodenal ulcer, including excision of the ulcer and restoration of intestinal integrity by suturing, characterized in that the anterior transverse rhomboid is 2/3 duodenotomy, the anterior wall of the duodenum is freed from cicatricial fusion, excision is performed intestines in the longitudinal direction, then they perform tunnel mobilization of one of the halves of the posterior intestine, conduct posterior duodenomentopexy to On the lateral wall and at the level of the middle of the ulcer bed, suturing of the posterior wall is performed in the longitudinal direction using precision microsurgical technique, the anterior wall of the intestine is sutured in the same direction, but in the transverse direction, and supplemented with anterior duodenomentopexy.

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