RU2177732C1 - Surgical method for treating callous ulcers of the lesser stomach curvature - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out economic stomach resection with pylorus being retained. Resection boundaries are determined from paled lesser curvature after performing intravenous injection of atropine sulfate or metacine. The lesser stomach curvature having ulceration defect inn given boundaries is resected. The lesser stomach curvature is subserously mobilized as bridge from subcardia to pes anserinus of Latarjet nerve. Suture line is peritonized. The sutures are additionally reinforced with built serous flap having lesser omentum. EFFECT: enhanced effectiveness in removing the most active stomach acid production zone; retained stomach innervation and blood supply. 7 dwg

Description

 The present invention relates to medicine and can be used in the surgical treatment of gastric ulcer, namely callous ulcers of lesser curvature.

 The most common surgical treatment for peptic ulcer is a resection of the stomach. Dissatisfaction with the long-term results of these operations leads to the need to evaluate the effect of various methods of gastric resection on the functional consequences of surgical intervention and prompts the search for ways to satisfy them. Thus, mortality after resection ranges from 2.4% to 3.2%, and the total number of complications is 13.8-18.7%.

 An analysis of long-term results after a gastrectomy in the last 25-30 years shows that a greater number of operated patients develop various functional disorders.

 According to A. Vinichenko (1), after resection of the stomach by Billroth-II, such disorders occur in 30% of patients, and in 3% of them in severe form. The reason for such disorders is in the very essence of Billroth-II methods, in which the duodenum is completely turned off from active digestion. In the study of the motor-evacuation function of the stump of the resected stomach by these authors, it was found that only 17.4% of patients operated by the Billroth-II method have a proportional emptying of the stump of the stomach in a period of 30 to 60 minutes. Most of the operated (82.6%) observed accelerated evacuation, and 23.2% - according to the type of lightning emptying.

 In the works of Onopriev V.I. (2), it was shown that functional resection occurs much less frequently with resection of the stomach using the Billroth-I method. Batch evacuation is observed in 67.4% of patients, occurring at a time close to normal. In less than 1/3 of the patients, evacuation was accelerated, while only 4.5% had fulminant evacuation.

 One of the important criteria for assessing the final outcome of an operation is the timing of rehabilitation and rehabilitation. Recovery or increased disability after gastrectomy by Billroth-I was noted in 78.3% of cases, by Billroth-II - in 65%.

 A decrease in working capacity with the Billroth-I method was noted in 17.4%, with the Billroth-II method - in 25% of patients. The onset of persistent disability was noted in 4.3% after Billroth-I interventions, and with Billroth-II resection, up to 11.3%.

 Having studied only these criteria (type of evacuation and working capacity), we can talk about the Billroth-I method as a more “physiological” method for gastric resection.

 Currently, indications for surgical treatment of peptic ulcer are the development of complications: bleeding, perforation, penetration, malignancy and the development of pyloric stenosis. At the same time, the issue of callous ulcers of the stomach remains debatable. The presence of a callous ulcer can also be attributed to complicated forms of peptic ulcer, since se malignancy is noted in 39-67% of cases. Scarring of a ulcerative defect on the background of conservative therapy occurs only in 3.8-9.4% of cases. Thus, the risk, first of all, of malignancy forces one to introduce the presence of callous stomach ulcers into the category of indications for surgical treatment of this pathology.

 Frequent (61-67%) formation of callous ulcers along the lesser curvature of the stomach correlates with a relatively low (compared to other areas) level of regional blood flow in the area of lesser curvature, as well as the most active acid production in this area.

 The long-term existence of kallose ulcers in the area of lesser curvature further aggravates the intensity of the decrease in regional blood flow, which, ultimately, sharply inhibits the reparative processes in the zone of the ulcer defect, and also increases the risk of malignancy.

 The most commonly performed gastrectomy. Moreover, the “classical” Billroth-I method, as well as its various modifications (Shalimov A.A.) (3) received the most widespread practice.

 In this regard, this method is "taken" as a prototype.

The Billroth-I resection method is performed in the following sequence:
1. Anesthesia - endotracheal anesthesia
2. Surgical access - upper median laparotomy.

 3. Audit of the abdominal organs, while clarifying the localization of a peptic ulcer and the required volume of resection of the stomach.

 4. The large curvature of the stomach is mobilized to the selected level of resection.

 5. Mobilization by small curvature.

 6. Before crossing the stomach, it is necessary to make sure that the gastroduodenoanastomosis will be superimposed without any tension: the site designated for the anastomosis from the side of great curvature freely approaches the duodenum. A clamp is applied to the stomach along the line of the upcoming resection and the mobilized part of the stomach is cut off. On a large curvature, a section of the stomach stump is left unstitched, the diameter of which is equal to the lumen of the duodenum. The rest of the stomach stump is sutured.

 7. The creation of gastroduodenoanastomosis occurs by converging the stump of the stomach and duodenum and applying a two-row suture.

 8. Suturing of the surgical wound.

 However, a significant drawback of this method of gastrectomy is the occurrence in 13-15% of cases of functional disorders associated with accelerated evacuation of food from the stomach, as well as a significant decrease in the intensity of blood flow in the gastric mucosa (35-38% lower than normal), especially expressed in the field of gastroduodenoanastomosis. A decrease in blood flow intensity in the anastomotic zone correlates with the incidence of postoperative complications such as anastomositis and peptic ulcer anastomosis. Thus, there is a decrease in the effectiveness of surgical intervention.

 The aim of the present invention is the removal of the most active acid-producing zone (lesser curvature of the stomach) with a pathological focus (callous ulcer), the maximum possible preservation of the innervation and blood supply of the gastric stump and the prevention of the development of dumping syndrome.

 This goal is achieved as follows.

 After the diagnosis is established, gastric ulcer, small curvature ulcer, corresponding to preoperative examination and preparation under endotracheal anesthesia, perform upper midline laparotomy and revision of the abdominal organs. Provide access to the stomach and conduct an atropine or metacin test to determine the boundaries of the proposed resection of lesser curvature of the stomach (Fig. 1). To do this, 1 ml of a 0.1% solution of atropine sulfate or 1 ml of a 0.1% solution of methacin is injected iv. At the same time, due to short-term redistribution of intragastric blood flow, blanching (up to 15 minutes) of small curvature occurs. This corresponds to the zone with the smallest regional blood flow and the most active acid production. A subserous mobilization of the lesser curvature of the stomach is performed, starting from the subcardia to the level of the “goose paw” of the Laterger nerve. Separation of the serous membrane is carried out along the lesser curvature in the form of a “bridge” 3-5 cm wide (Fig. 2).

 The apparatus UKL-40 or ETHICON TST 55 or ETHICON TLT / TPH 30 (60) is phased through the formed “window”, and the walls of the stomach are stitched twice with parallel tantalum sutures along the intended line of resection (Fig. 3). Resection of the lesser curvature of the stomach with a peptic ulcer between the lines of tantalum sutures is performed (Fig. 4). The seam line is peritonized with separate interrupted sutures (Figs. 5 and 6). Then, the suture line is additionally peritonized by the previously separated serous membrane (serous "bridge") with individual interrupted sutures (Fig. 7). The abdominal cavity is drained. The surgical wound is sutured in layers tightly.

 This method of resection allows you to eliminate the pathological focus along with the most active acid-producing zone. At the same time, there is no transverse intersection of the stomach, which ensures the preservation of intraparietal neuromuscular connections, which, in turn, provides earlier restoration of the motility of the operated stomach; the lumen of the stomach is not opened, which contributes to a significant reduction in wound infection; the function of pyloric pulp is preserved, which provides conditions for natural digestion.

Case Studies
Example 1. Patient M., 41 years old, a driver by profession, was hospitalized in the surgical department of the mountains. hospital 7, Rostov-on-Don from 03.15 to 03.28.98, with a diagnosis of peptic ulcer, ulcerative ulcer of lesser curvature. For 8 years he has been suffering from peptic ulcer; he was repeatedly treated in the therapeutic department. In the last 14 months, the ulcer is constantly recurring in nature, the pain syndrome intensified. No effect was obtained from conservative therapy. When FGDS dated 03/04/98, an ulcer was revealed on the lesser curvature of the stomach with a diameter of up to 1.5 cm, a depth of up to 0.5-0.7 cm, along the edge of the ulcer, a kallous shaft, the edges of the ulcer were saped. At the bottom of the ulcer, fibrin deposits. In the study of biopsy samples - in the edges of the ulcer "coarse-fibrous connective tissue, areas of necrosis" - no signs of malignancy of the ulcer were detected. With a pH meter of March 16, 1998 a normoacid state was detected (pH 2.3).

 After the preoperative preparation 03/20/98. under combined endotracheal anesthesia performed upper midline laparotomy. With resection: the lesser curvature of the stomach below the esophagus by 5-6 cm determines ulcerative infiltration up to 2-2.5 cm in diameter, no other pathology was detected.

 After the atropine test, the boundary of the proposed resection is outlined. A subserous mobilization of the lesser curvature of the stomach was performed over 12 cm. The serous membrane was separated along the lesser curvature in the form of a “bridge” up to 3.5 cm wide. A UKL-40 stapler was inserted into the resulting “window”, and two stages were stitched along the outlined border of the stomach wall rows of tantalum seams. Small curvature of the stomach along with a peptic ulcer is resected between the joints. The newly formed small curvature is peritonized by separate interrupted sutures. An additional peritonization of the suture line was performed due to the separated portion of the serous membrane.

 The abdominal cavity is drained, sutured in layers tightly. The postoperative period was uneventful, without complications (peristalsis is determined from the end of the first day, with electrogastrography, the normokinetic type of peristalsis is determined from 3 days), the sutures were removed on the 7th day. The patient was discharged for outpatient observation on the 8th day after surgery.

 After 14 days, the patient was examined: no complaints, good appetite. In FGDS, the suture line along the lesser curvature is slightly hyperemic. The gatekeeper is closed, we pass freely. With pH-metry - hypoacidity. When X-ray of the stomach, the state after resection of the lesser curvature of the stomach: the stomach is in the form of a “hook”, the barium suspension is discharged into the duodenum portion, after 1 hour in the cult of the stomach 1/3 of the contrast, after 3 hours in the cult of the stomach traces of contrast.

 The patient was examined again after 3 months after surgery: no complaints, diet does not comply. He gained 3 kg in weight, works in his specialty.

 With FGDS: the mucous membrane of the stomach is pale pink, the line of sutures according to the lesser curvature is not clearly defined. The gatekeeper is closed, we pass freely. When radiography of the stomach: relief portion dose. After 1 hour, 1/3 of the contrast remains in the stomach, after 3 hours there are traces of contrast in the cult of the stomach.

 Example 2. Patient V., 34 years old, profession - builder, was hospitalized in the surgical department of the mountains. hospital 7, Rostov-on-Don from 05.17 to 01.06.98, with a diagnosis of peptic ulcer, a giant callous ulcer of lesser curvature of the stomach. Sick for 11 years. In the last 2 years, the ulcer does not heal. 8 months ago he was hospitalized for "ambulance" in connection with the occurrence of ulcerative bleeding. He refused the proposed operation, the bleeding was stopped by conservative methods. In the last 5-6 months, constant pain, aggravating after eating, nausea, general weakness, anorexia, weight loss, began to disturb.

 With multiple FGDS, there is a giant (up to 4 cm in diameter) ulcer along the lesser curvature of the stomach. Ulcer crater up to 0.8 cm deep. At the bottom there are sections of necrotic masses covered with fibrin. The edges are sap, the ulcer is limited by a kallous shaft up to 4 mm wide. Histological examination of biopsy samples from the edges and bottom of the ulcer showed no signs of malignancy (coarse-fibrous connective tissue with areas of necrosis was detected).

 After a preoperative examination and preparation on 05/20/98, an upper-mid laparotomy was performed under endotracheal anesthesia. During the audit, it was established: according to the lesser curvature of the stomach below the esophagus by 4-5 cm there is an ulcerative infiltrate, partially passing to the front wall of the stomach with a diameter of up to 5 cm. Adhesion is noted in the area of infiltration.

 After separation of adhesions with a further revision of another pathology of the abdominal organs was not found.

 A metacin test was performed and the area of the proposed resection was determined. Produced subserous mobilization of lesser curvature. The serous membrane is separated along the lesser curvature in the form of a “bridge” up to 4.0 cm wide. A UKL-40 stapler is inserted into the formed “window”, and two rows of tantalum sutures are stitched in stages along the outlined border of the stomach wall. Small curvature of the stomach along with a peptic ulcer is resected between the suture lines. The newly formed small curvature is peritonized by separate interrupted sutures. An additional peritonization of the suture line was performed due to the separated portion of the serous membrane.

 The abdominal cavity is drained, sutured in layers tightly. The postoperative period was uneventful, without complications, active peristalsis was determined from the end of the first day, with electrogastrography, the normokinetic type of peristalsis was recorded after 2.5 days. Sutures were removed on the 7th day. The patient was discharged for outpatient observation on the 8th day after surgery.

 The patient was examined after 16 days: no complaints, good appetite. With FGDS: moderate hyperemia of the gastric mucosa, which is more pronounced along the lines of small curvature sutures. The gatekeeper is closed, we pass freely.

 When fluoroscopy: relief contrast in the duodenum portion, after 1 hour in the stomach 1/3 of the contrast, after 3 hours in the cult of the stomach traces of contrast.

 The patient was examined again after two months. No complaints, no diet. Disability fully recovered 1.5 months after surgery, recovered by 3.5 kg.

 With FGDS: the mucous membrane of the stomach is pale pink, the line of sutures according to the lesser curvature is not clearly defined. The gatekeeper is closed, we pass freely. When radiography of the stomach: relief portion dose. After 1 hour, 1/3 of the contrast remains in the stomach, after 3 hours there are traces of contrast in the cult of the stomach.

Analysis of the treatment of 32 patients operated on by the "classical" Billroth-I method and its comparison with the treatment results of 13 patients operated on by the claimed method show:
1. In patients operated on by the claimed method, with electrogastrography, the normokinetic type of peristalsis is determined on the 3-4th day after the operation, and when using the "classical" Billroth-I method - on the 5-6th day after the operation.

 2. In 98% of patients operated on by the claimed method, there is a batch type of evacuation, and when using the "classical" Billroth-I method, in 64%.

 3. Previously, disability is restored - after 1.5-2 months with the claimed method and after 3-4 months in the control group.

 4. There are no post gastroresection complications.

 These advantages are the result of economical resection of lesser curvature along with a callous ulcer, without crossing the stomach and preserving the pylorus.

Literature
1. Vinichenko A. V. "Clinical and physiological aspects of gastroplasty in the surgical treatment of gastric ulcer." Abstract. dis. for a job. D.M.N. - Krasnodar, 1998.

 2. Onopriev V.I. et al. "Extended medial resection of the stomach." Scientific conf. "Stomach ulcer". Abstracts - Krasnodar - Anapa, with. 112 - 116.

 3. Shalimov A.A. et al. "Surgery of the digestive tract." - Kiev: publishing house "Health", 1987, p. 175 - 188.

Claims (1)

 A method of surgical treatment of gastric ulcer, including economical gastric resection with preservation of the pylorus, characterized in that the borders of the resection are determined by blanching of lesser curvature after intravenous administration of 1.0 ml of 0.1% solution of atropine sulfate or metacin, then lesser curvature with a clear defect is resected within certain boundaries, subserously mobilizing the lesser curvature of the stomach in the form of a bridge 3-5 cm wide from the subcardia to the level of the “goose paw” of Latarge’s nerve, after which the suture line is peritonized with their additional epleniem formed with a small flap serous gland.

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