RU2176483C2 - Surgical method for treating chronic duodenal impassibility - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves resecting antral region of the stomach. The duodenum is sutured. Vagotomy is carried out. Duodenojejunal passage is mobilized. Gastrojejunal anastomosis is created on short loop. The jejunum is transected 15 cm apart from the anastomosis. The distal end of the transected intestine is anastomosed with inferior horizontal part of the duodenum to the right from mesenterial blood vessels. The proximal end of the transected intestine is end-to-side anastomosed with small intestine 15 cm apart from the duodenojejunal anastomosis. EFFECT: improved evacuation of the duodenum. 4 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used to treat chronic duodenal obstruction.

 A known method of treating chronic duodenal obstruction, in which, after a typical stem vagotomy with an antrumectomy, the duodenal stump is sutured with one of the known methods. The duodenojejunal junction is mobilized and the duodenum is crossed immediately after the Treitz ligament, after which the distal stump of the duodenum is moved to the right of the mesenteric vessels. The initial loop of the small intestine is mobilized and a small intestine insert is formed, one end of which is anastomosed with the duodenum, and the other end is with a loop of the small intestine at a distance of 40 cm from the posterior-gastroenteroanastomosis (Surgery, 1988, No. 3, p. 116-117).

 The disadvantage of this method is the complexity and trauma of suturing the distal stump of the duodenum and the formation of the small intestine insert.

 The invention is aimed at solving problems: simplifying the method, increasing efficiency by improving the emptying of the duodenum, prevention of the syndrome of the leading loop.

 Tasks are achieved by crossing the duodenum and small intestine once with the reduction of the duodenojejunal junction and the imposition of gastroenteroanastomosis and duodenojejunoanastomosis.

 The novelty of the method is that the duodenum is crossed and sutured once, the duodenojejunal transition is reduced and the gastroenteroanastomosis is placed on a short loop, the small intestine for anastomosis with the duodenum is crossed once.

 The method is depicted in the diagram, where in FIG. 1 shows an antrumectomy with selective proximal vagotomy, intersection and suturing of the duodenal stump, and reduction of the duodenojejunal junction. In FIG. 2 shows a gastroenteroanastomosis on a short loop, the intersection of the small intestine distal to the anastomosis by 15 cm. In FIG. 3 shows an anastomosis of the duodenum with a distal end 2 of the crossed loop of the small intestine. In FIG. 4 shows the inter-intestinal anastomosis of the small intestine with the proximal end 1 of the previously crossed small intestine, the final type of operation.

 The method is as follows. To suppress gastric secretion, a selective proximal vagotomy with an antrumectomy is done, the duodenum is crossed and sutured in one of the known ways, the duodenojejunal junction is mobilized and reduced by dissection of the Treitz ligament (Fig. 1). Gastroenteroanastomosis with the initial section of the small intestine is applied, after which the small intestine is crossed at a distance of 15 cm from this anastomosis (Fig. 2). The distal end 2 anastomose with the lower horizontal part of the duodenum to the right of the mesenteric vessels (Fig. 3). The proximal end 1 of the previously crossed intestine anastomose with the small intestine "end to side" at a distance of 15 cm from the last anastomosis (Fig. 4).

 Examples of specific performance.

 1. Patient I., b. 1959 , was admitted to the Perm Regional Hospital 12/23/97, with complaints of constant aching pain in the epigastric region, aggravated after eating, accompanied by nausea and vomiting. Sick since 1991, when perforation of a duodenal ulcer occurred - the operation of suturing a perforated ulcer.

 FGS: the esophagus without features, in the stomach a fluid colored with bile, the antrum mucosa is hyperemic. The gatekeeper is deformed by a scar, yawns. The duodenal bulb is scarred, narrowed, and a wide lumen below.

 X-ray of the stomach: we pass the esophagus, cardiac pulp is functioning. An empty stomach contains a little fluid, mucus. The contours are even, folds are thickened, swollen, peristalsis is sluggish, of small amplitude. The pylorus is deformed, elongated, does not completely close, throwing contrast from the duodenum into the stomach. The duodenal bulb is deformed, does not differentiate. The duodenal loop is usually deployed, in the lumen of its mucus, fluid, the progress of contrast is slowed down. Conclusion: radiological signs of gastroduodenitis, cicatricial deformity of the duodenal bulb and pylorus.

 Operation 01/20/98, Laparotomy, adhesion process in the abdominal cavity. The output section of the stomach and the duodenum, which is sharply expanded (6-7 cm), filled with air and liquid, are isolated from the joints, rumbles, does not empty. On the lateral contour, in the projection of the hepatoduodenal ligament, cicatricial cords, significantly deforming the duodenum, several encapsulated ligatures. A commissural process is expressed in the area of the duodenojejunal transition, the adhesions are dissected together with the Treitz ligament. There are signs of arteriomesenteric compression of the lower horizontal duodenal ulcer.

 Mobilization and resection of the antrum with vagisection of the stump. The duodenum is crossed and sutured open way. A short loop gastroenergoanastomosis has been imposed. 15 cm from it, the small intestine is crossed, the distal end is anastomosed with the lower horizontal section of the duodenum to the right of the mesenteric vessels "end to side", and the proximal end of the crossed intestine is anastomosed with the small intestine "end to side". An irrigator for probe feeding was carried out.

 The postoperative period without complications, 2.02.98, was discharged in satisfactory condition.

 Examined after 1 year: no complaints, able-bodied, lack of body weight. X-ray of the stomach: the stump of the stomach is conical in shape, evacuation is free, portioned, the “leading loop” is periodically filled, but is immediately emptied through duodenoeunoanastomosis.

 2. Patient V., born in 1955, was admitted to the Department of General Surgery of the Perm Regional Clinical Hospital on February 13, 1998 with complaints of pain in the epigastric region, aggravated after eating, nausea, vomiting, belching with air. Considers herself ill since 1976.

 FGS: in the lower third of the esophagus, the mucosa is whitish, the folds are thickened, the cardiac pulp closes. The stomach has a clear liquid, on the back wall of the body there is a bright spot of hyperemia. The pylorus closes, the duodenal bulb with a post ulcerated scar that does not deform the intestine. Conclusion: post ulcerated duodenal scar.

 X-ray of the stomach: we pass the esophagus, the cardia is not changed. In the stomach, fluid, mucus, folds are rough, the contours are even, the peristalsis is deep. The duodenal bulb is scarred, irritated, with fluid. There is a small, painful "niche" in the bulb. The duodenal loop is usually deployed, wide, with pronounced antiperistalsis, barium reflux from the duodenum to the stomach. In the lower horizontal branch, narrowing, more pronounced when standing on the back. Conclusion: cicatricial ulcer deformation of the duodenum, gastritis, radiological signs of arteriomesenteric compression and obstruction of the duodenum.

 Probe duodenography: through the probe, the duodenum, which is expanded, is contrasted, with antiperistalsis. In the lower horizontal branch, its vertical, linear filling defect due to compression by the vessel. Conclusion: X-ray picture of arteriomesenteric obstruction of the duodenum.

 Duodenomanometry: duodenal hypertension (160-220 mm aq. Column).

 Operation 03/11/98, Median laparotomy. The stomach is large, its wall is hypertrophied. In the area of the duodenal bulb, fibrous adhesions, scars, deforming the intestine. Below the duodenum expanded to 6 cm, sagging in the lower horizontal region, squeezed by the mesenteric vessels. In the area of duodenojejunal transition of fusion, but the intestine is of normal size. The adhesions are eliminated, the Treitz ligament is dissected, the duodenojejunal transition is reduced. Mobilization of the stomach and bulb of the duodenum below the site of the ulcer, the duodenum is crossed, sutured by the apparatus and the purse string suture. Antrumectomy, vagotomy of the stomach stump, gastroenteroanastomosis on a short loop. At a distance of 15 cm from it, the small intestine is crossed, the distal end is anastomosed with the lower horizontal section of the duodenum to the right of the mesenteric vessels with an end-to-side transverse anastomosis, while dark, stagnant bile is released from the lumen of the duodenum. 15 cm from this anastomosis, an end-to-side inter-intestinal anastomosis was placed between the small intestine and the proximal end of the previously crossed intestine. An irrigator was carried out for enteral nutrition in the outlet loop, which is fixed to the posterior lip of the interintestinal anastomosis.

 Preparation: mucosal atrophy is expressed in the antrum, cicatricial deformity and narrowing of the intestine in the area of the duodenum.

 In the postoperative period, anastomositis was observed with a violation of the evacuation from the stomach, which were stopped by conservative measures, nutrition was carried out through an irrigator.

 Control fluoroscopy 03/20/98. The stump of the stomach is large, contains fluid, evacuation is slowed down, after 1 hour a little contrast in the small intestine. 03/21/98. After 24 hours, the main part of the contrast in the colon and distal ileum, traces of barium in the stomach. Discharged on March 24, 98. in satisfactory condition.

 The positive effect of using the proposed method consists in simplifying the method by crossing and suturing the duodenum once, lowering the duodenojejunal junction and applying a gastroenteroanastomosis in a short loop, crossing the small intestine for duodenojunoanastomosis once, increasing the efficiency and prevention of the “leading loop syndrome” due to a dual way of emptying the duodenum.

Claims (1)

 A method for surgical treatment of duodenal ulcer with chronic duodenal obstruction, including resection of the antrum, vagotomy, suturing of the duodenum, application of gastroenteroanastomosis and duodenoenterostomy, characterized in that after suturing of the duodenodenoderma, cross the jejunum at a distance of 15 cm from it, then the distal end of the crossed intestine nastomoziruyut with nizhnegorizontalnoy part of the duodenum to the right of the mesenteric vessels, and the proximal end of the cross intestine anastomose to the small intestine by the type of end-to-side at a distance of 15 cm from the duodenoeyunoanastomoza.

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