RU2192171C2 - Method for developing an areflux cardia - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the method deals with surgical treatment of ulcerous disease. At first, one should fix the fundus of the stomach to the esophagus. Symmetrical fundapplicational cuff is developed by suturing anterior and posterior stomach wall at similar distance against the lesser curvature of stomach from stomach's corner towards esophagus. One should restore ligamentous apparatus of the stomach. Moreover, a cuff is fixed at the places of its adjoining to the diaphragm. EFFECT: higher efficiency in preventing deformations of the stomach. 7 dwg

Description

 The invention relates to surgery, in particular to the surgical treatment of duodenal ulcer.

 For surgical treatment of complications of duodenal ulcers by vagotomy to eliminate cardiac sphincter insufficiency due to mobilization of the abdominal esophagus, the method of forming areflux cardia, which consists in the formation of an areflux cuff around the abdominal esophagus, is used.

 There is a method of forming areflux cardia when performing selective proximal vagotomy, which consists in suturing the bottom of the stomach to the esophagus, fixing the walls of the stomach to the diaphragm, and then creating a fundoplication cuff around the esophagus on a top-down basis (V. Onopriev Etudes of functional surgery for peptic ulcer . - Krasnodar, 1995 .-- 296 p.).

However, this method has the following disadvantages:
- with this sequence of formation of the cuff, it is difficult to evenly distribute the seams around the circumference of the cuff to ensure its symmetry. This is due to the fact that it is immediately difficult to determine the point of suturing on the walls of the stomach and esophagus due to their great distance from each other, their location in different planes on the walls having different elasticities. This can lead in the future to the formation of deformations of the type of "cascading" stomach and a violation of evacuation from the stomach;
- the formation of the cuff immediately begins with suturing at the most distant from each other points of the anterior and posterior walls of the stomach. When tightening the seams, a strong tension arises, which can lead to their eruption;
- it is especially difficult with this method to suture an already fixed posterior wall of the stomach.

 The closest analogue is the method of forming areflux cardia, which consists in the formation of a cuff according to the "bottom-up" principle by suturing from the corner of the stomach towards the esophagus (Chernousov A.F., Bogopolsky P.M., Kurbanov F.S. diseases of the stomach and duodenum. - M .: Medicine, 1996. - 253 p.).

The specified analogue has the following disadvantages:
- possible cuff sliding due to insufficient fixation of the bottom of the stomach;
- it is impossible to control the rotational displacement of the cuff along the axis of the esophagus;
- fixing the bottom of the stomach to the esophagus with an already formed cuff is difficult and possible only at the highest point, which weakens the areflux properties of the cuff.

 The objective of the invention is to simplify the formation of areflux cardia, to ensure maximum symmetry of the fundoplication cuff, to prevent deformation of the stomach, as well as slipping and rotational mixing of the cuff.

 To solve the problem after mobilization of the abdominal esophagus (Fig. 1), the bottom of the stomach is sutured to the esophagus with 3-4 sutures (Fig. 2), and then a symmetrical fundoplication cuff is formed by suturing the front and back walls of the stomach at the same distance from the lesser curvature (in the direction from the angle of the stomach to the esophagus) (Fig.3, 4). The restoration of the ligamentous apparatus of the stomach is carried out by fixing a symmetrical cuff in places of its fit to the diaphragm (Fig. 5), which ensures uniform tension of the joints and better physiology.

The advantages of this method:
- uniform tension of the seams, since the first seams in the region of the angle of the stomach are superimposed at a small distance from each other, are tied with a minimum tension, while reducing the tension for the next seam;
- the formation of the most critical stage - the creation of a metered compression of the abdominal esophagus is carried out with a minimum tension of the joints;
- the formation of an absolutely symmetric cuff and the absence of conditions for its rotational displacement, since fixation is carried out strictly along the line of small curvature of the stomach and the bottom (in the same plane, along the anatomical landmarks of the ligamentous apparatus of the stomach);
- final fixation of the cuff in places of its contact with the diaphragm ensures uniform tension of the joints, does not affect the shape and properties of the cuff, provides good control of rotational displacement and, therefore, better physiology.

 Example 1. Patient K., 42 years old, medical history 3-123. Regarding subcompensated stenosis of the duodenal bulb, the patient underwent radical duodenoplasty and selective proximal vagotomy, while the lesser curvature of the stomach and the abdominal esophagus were mobilized. Areflux cardia created by the method of V.I. Onoprieva. In the postoperative period, the patient noted dysphagia for a long time - a feeling of difficulty in passing solid food through the esophagus, aching pains behind the sternum, pressing pains in the epigastrium. At control endoscopic examinations after 0.5 years and 1 year after the operation - there are signs of moderate esophagitis in the lower third of the esophagus, the cardia is closed, but it requires effort, the proximal sections of the stomach are deformed. An X-ray examination showed a "cascading" deformation of the stomach (Fig. 6), signs of rotational displacement of the abdominal esophagus. According to the daily pH-meter, complete areflux is not achieved - gastroesophageal refluxes are recorded.

 Example 2. Patient F., 44 years old, medical history 4-1524, was operated on for a duodenal ulcer, complicated by subcompensated stenosis, bleeding and reflux esophagitis. Areflux cardia is formed according to our proposed method. The time spent on surgery is 20 minutes, despite the technical difficulties caused by the acute epigastric angle. The postoperative period is smooth. Examined 1 year after the operation - no complaints. With an endoscopic examination, there are no signs of esophagitis, the cardia closes completely, but is freely passable for the endoscope, and no deformation of the stomach has been detected. When x-ray examination of any deformation of the proximal stomach is not detected (Fig.7). At daily pH-metry, the complete areflux of the fundoplication cuff is confirmed - gastroesophageal refluxes are not recorded.

 The method can be used to treat patients with gastric ulcer and cardiac reflux disease. Applied in 12 patients with duodenal ulcer. No complications associated with the implementation of the technical reception were noted.

Claims (1)

 The method of forming the areflux cardia, which consists in forming a cuff by suturing from the corner of the stomach towards the esophagus, characterized in that the bottom of the stomach is fixed to the esophagus, then a symmetrical fundoplication cuff is formed, stitching the front and back walls of the stomach at the same distance from the lesser curvature in the direction from the corner of the stomach to the esophagus, and then restore the ligamentous apparatus of the stomach, fixing the cuff in places of its fit to the diaphragm.

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