RU2199279C1 - Method for duodenopylorogastroplasty in surgery of gastroduodenal ulcers complicated with prolonged pylorobulbar stenosis - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: one should carry out distal gastric resection. At the distal end of gastric stump one should circularly resect serous-muscular membrane up to submucous layer. Serous-muscular membrane should be separated and folded upwards to form a circular valve. Distally against a scar-changed bulb one should circularly resect serous-muscular membrane. Anastomosis is applied between gastric transplant and duodenum. Along posterior and anterior walls of gastric transplant one should make per one longitudinal relaxing incision of serous-muscular membrane. The method in question enables to prevent regurgitant and postresectional complications. EFFECT: higher efficiency of operation. 3 dwg, 1 ex

Description

 The invention relates to medicine, specifically to methods for surgical treatment of patients with pyloric bulbar ulcers complicated by extended pyloric bulbar stenosis (PBS).

 There is a method of surgical treatment of patients with complicated forms of gastroduodenal ulcers, which consists in performing distal resection of the stomach and the anterior wall of the rumen-ulcerative duodenal bulb (duodenum) with subsequent duodenopylorhastroplasty, while the separated muscle fibers of the pyloric pulp with preserved neurovascular 3 cm 3 end of the stump of the stomach into a circular defect of the serous muscle cover of the latter and fix to it with sutures, then impose g astroduodenoanastomosis of the type end to end [1]. However, the use of this method in patients suffering from peptic ulcer complicated by prolonged PBC is limited by the loss in most cases of the functional activity of the output section of the stomach when the pyloric pulp is involved in the stenotic scar-ulcer process, in addition, despite the decrease in the number of motor-evacuation disorders, this technique does not excludes the development in the postoperative period in a number of patients of reflux gastritis due to insufficient areflux function of the formed gastroduodenal of transition.

 A new technical result - expanding the scope and increasing the effectiveness of treatment due to the prevention of regurgitation post-resection complications is achieved by using a new method of treatment, which consists in performing distal gastric resection followed by duodenopilorogastroplasty, and the stomach stump is formed in the form of a conical tube at the end of 25-30 mm wide, length 8-12 cm, at the distal end of which, departing from the edge of the resection by 35-40 mm, the serous-muscular membrane is circularly dissected to the submucosa oia, which is exposed to a width of 8-10 mm, after which the serous-muscular membrane proximal to the section is separated to a width of 10-12 mm, wrapped up and hemmed with a free edge to the serous membrane of the gastric stump in a state of moderate tension both in longitudinal and transverse direction, thus forming a pyloric pulp, then separate nodal sutures are inserted passing through the lower edge of the formed muscle pulp and the upper edge of the serous-muscular membrane of the gastric stump, with an excess of mucous-submucosal layers in the stump of the stomach in the form of a duplicate, they invaginate into the lumen of the distal part of the gastric tube - the gastric transplant, forming a circular valve, then the sero-muscular membrane of the duodenum is distal to the scar-modified bulb circularly dissected, exposing the submucous base to a width of 8-10 mm, after which nodular s on the posterior semicircle of the anastomosis, passing respectively through the distal and proximal edge of the sero-muscular membrane of the gastric transplant and duodenum, thereby, the second row of sutures is applied by the method of two oncoming catgut sutures, stitching the submucosal layers of the posterior wall of the anastomosis, departing from the first row of sutures by 1-2 mm, then the mucous membrane of the posterior and anterior semicircles of the gastric transplant and duodenum is circularly cut off, departing 2 mm from the applied catgut suture, the remaining catgut sutures first suture the submucous layers of the right and then the left semicircles of the anastomosis, after which separate serous-muscular sutures are placed on the anterior semicircle anastomosis, then along the posterior and anterior walls of the gastric transplant, departing from the gastroduodenoanastomosis 2-3 mm, perform one longitudinal laxative section of the serous-muscular membrane, not reaching the pyloric pulp 2-3 mm.

 The method is as follows.

 Perform a tubular resection of the stomach with parietal mobilization, while the formed stomach stump in its distal part is presented in the form of a cone-shaped tube with a width at the end of 25-30 mm, a length of 8-12 cm. At the distal end of the tube, 30-35 mm away from the edge of the resection serous-muscular sheath is circularly dissected to the submucosal layer, which is exposed to a width of 8-10 mm, after which the serous-muscular sheath proximal to the incision is separated to a width of 10-12 mm, wrapped up and stitched with a free edge to the serous membrane of the cult and the stomach in a state of moderate tension both in the longitudinal and in the transverse direction, thus forming a pyloric pulp (Fig. 1).

 After this, separate nodal sutures are inserted, passing through the lower edge of the formed muscle pulp and the upper edge of the serous-muscular membrane of the stomach stump. The sutures are alternately tied and at the same time an excess of the mucous-submucous layers of the stomach stump in the form of a duplicate invaginate in the lumen of the distal part of the gastric tube - the gastric transplant, forming a circular valve.

 The duodenal stump is pulled into the wound by the holders. Its serous-muscular membrane distal to the scarred bulb is circularly dissected, exposing the submucosal base to a width of 8-10 mm. Nodal sutures are applied to the posterior semicircle of the anastomosis: the distal and proximal edges of the serous-muscular membrane of the gastric transplant and duodenum are respectively taken into the suture. After applying 4-5 sutures, they are tied (Fig. 2).

 Then a second row of sutures is applied by the method of two oncoming catgut sutures 40-50 cm long on an atraumatic needle, stitching the submucosal layers of the posterior wall of the anastomosis, 1-2 mm from the first row of sutures. Moreover, the angles of anastomosed organs are stitched in the first place. The width of the steps is 2 mm.

 Thin scissors circularly cut off the mucous membrane of the posterior and anterior semicircles of the gastric transplant and duodenum, retreating 2 mm from the applied catgut suture. The remaining catgut sutures are first sutured to the submucous layers of the right and then the left semicircle of the anastomosis. The threads are slightly tightened, tied and cut off. After this, separate nodular serous-muscular sutures are imposed on the anterior semicircle of the anastomosis.

 Then, along the back and front walls of the gastric transplant, departing from gastroduodenoanastomosis 2-3 mm, one longitudinal laxative section of the serous-muscular membrane is performed, not reaching the sawmill pulp 2-3 mm (Fig. 3), thus creating a sufficient volume of the artificial bulb KDP.

 Examples of specific applications of the method.

 Patient A., 34 years old, was admitted as planned to the I surgical department on 04/16/99. with a diagnosis of direction: Duodenal ulcer, complicated by cicatricial and ulcerative deformity of the duodenal bulb, subcompensated stenosis. Condition after suturing of perforated ulcer of the duodenal bulb from 1997. He suffers from peptic ulcer for 8 years, repeatedly underwent a course of inpatient and spa treatment. Two years ago he underwent suturing of a perforated ulcer of the anterior wall of the duodenal bulb. Over the past year, he has noted exacerbations of peptic ulcer three times with increased intensity of pain, the periodic appearance of belching with the smell of “rotten eggs”, bitterness, a feeling of quick satiety and heaviness in the epigastric region after eating. Periodically induces vomiting on its own. The loss of body weight over the past year was 7 kg.

 With FGDS: In the lower third of the esophagus and cardia, the mucous membrane is hyperemic, swollen with single erosions. The stomach is large, in the lumen there is muddy mucus and the remnants of food eaten the day before; the mucosa is hyperemic, edematous with sporadic erosion in the distal region. The pylorus and the duodenal bulb are roughly scarred, deformed, narrowed to 7-8 mm, and hardly passes the tube of the device. On the back wall of the duodenal bulb in the scars there is a deep ulcer up to 12 mm in size, with uneven edges, covered with fibrin. In the lower sections of the duodenum are signs of duodenitis. Conclusion: Chronic ulcer of the posterior wall of the duodenal bulb. Penetration. Rough cicatricial-ulcerative stenosing deformity of the pyloric bulbar department. Distal erosive esophagitis, erosive gastritis, duodenitis. When x-ray examination: the esophagus is not changed. The stomach is standing abruptly stretched with plenty of fluid. Peristalsis is superficial. There is no evacuation of the caustic mass. At control fluoroscopy after 2 hours there is no evacuation from the stomach. During control fluoroscopy after 4 hours, a sharply deformed pyloric canal is contrasted with a shortened and reduced in volume bulb of the duodenum, the large curvature of which determines an ulcer niche up to 1.0 cm in size. After 12 hours, traces of barium are noted in the initial parts of the colon, but most barium remained in the stomach. There are no signs of duodenostasis. Conclusion: Ulcer of the duodenal bulb. Cicatricial deformity of the pylorus and the duodenal bulb. Subcompensated stenosis of the pyloric bulbar department.

 In the study of gastric juice revealed hyperchlorhydria.

 For 10 days, the patient underwent intensive preoperative preparation, including daily double washing of the stomach with antiseptic solutions, infusion therapy aimed at restoring the acid-electrolyte balance, transfusion of native plasma, protein preparations.

 On April 27, 1999, the patient underwent surgery: Distal gastrectomy in the volume of 1/2 organ with duodenopilorogastroplasty. Esophagofundoraphia.

 Diagnosis after surgery: Duodenal ulcer. Chronic ulcer of the posterior wall of the duodenal bulb, complicated by penetration into the hepatoduodenal ligament. Subcompensated scar-ulcerative total pyloric bulbar stenosis. Condition after suturing of the perforated bulb of the duodenum from 1997

 In the postoperative period, during the first 5 days, enteral nutrition was performed through a microprobe, decompression of the stomach stump with a nasogastric tube for 4 days. On the 6th day after the restoration of motor-evacuation function of the stomach, a control endoscopic examination was performed, in which there were signs of moderate hypotension of the stomach. Allowed food through the mouth in accordance with the appropriate diet. Sutures were removed on the 9th day, healing by first intention. The patient was discharged in satisfactory condition with recommendations on the regimen and diet.

 During a comprehensive examination two months after the operation, the patient had no complaints. The weight is stable, the stool is regular, does not follow a diet, does not note dyspeptic disorders. Clinical evaluation of Visick surgery is excellent. When x-ray examination of the esophagus freely pass, the cardia closes. The stomach is medium-sized, empty on an empty stomach. With tight filling, the contours are even, clear. Primary evacuation - in two minutes, portioned. A sufficient volume gastric transplant is well filled with a contrasting suspension; in the proximal part of the latter, the valves of the invagination valve are visualized in the form of two lip-shaped filling defects that are actively closed after the evacuation of a portion of the contrast medium. The tone of the duodenum is normal, peristalsis is not broken. Signs of GDR in a standing position and in the Trendelenburg position were not detected.

 With endoscopic examination, the esophagus is not changed, the cardia is closed. The stomach is medium in size, there is light mucus in the lumen, there is no bile impurity, the folds are longitudinal, high, converge to an artificial pyloric canal; the latter is closed, revealed during insufflation with air, freely pass. The gastric transplant mucosa is pink, moderately edematous, and there are no defects. The anastomosis is oval, yawns, we pass freely, the mucous membrane in the anastomosis zone is pink, there are no defects. Mucous duodenum is not changed. Conclusion: the condition after resection of the stomach with duodenopilorogastroplasty.

 In the study of gastric juice revealed hypochlorhydria, bile acids were not found. Morphological examination of the mucosa of the distal stomach: superficial gastritis.

 The patient was discharged in satisfactory condition. Disability restored completely.

 Justification of the regime.

 The creation of optimal conditions for the compensation of the digestive functions in patients with extended scar-ulcer transformation of the pyloric bulbar region is possible only by restoring the anatomical proportions of the gastroduodenal transition and the formation of structures simulating the lost function of the natural sphincter mechanisms of the upper gastrointestinal tract, which do not interfere with the physiological passage of food and at the same time prevent the development of reflux disease.

 Based on this, the expansion of the field of use and prevention of postoperative regurgitation complications is achieved by performing a distal tubular resection of the stomach and replacing the stenotically scarred pyloric bulbar section with a gastric transplant with the formation of an artificial pylorus, with strictly layered dissection and stitching of anastomosed organs and using the proposed numerical parameters of the elements used on various stages of the formation of a gastric transplant and art ennogo pylorus.

 A transplant of a sufficient length and volume formed from the distal section of the stomach stump fully functionally compensates for the resected stenotic-scarred proximal sections of the duodenum, and a saw-like pulp 10-12 mm wide formed using a circularly separated muscle shell in conjunction with a circular invagination valve 15-18 mm high is an artificial pylorus, preventing the development of dumping syndrome, providing reliable areflux properties vannomu pilorobulbarnomu transition.

 The method was tested on 3 patients.

 The clinical application of the developed method for the surgical treatment of pyloric bulbar ulcers complicated by pyloric stenosis made it possible to fully compensate the digestive functions and prevent the development of post-resection complications.

 Thus, clinical observation data indicate that the use of the developed surgical intervention - duodenopilorogastroplasty after distal gastric resection, aimed at restoring the anatomical proportions of the gastroduodenal transition and replacing the lost function of the pyloric pulp, allows, in the end, to carry out social and labor rehabilitation of patients, improve the quality of life operated patients with extended cicatricial-ulcerative transformation of the pyloric bulbar region.

Sources of information
1. Naumov V.F., Shpalinsky G.V., Gabdraupova S.R. et al. Duodenopylorogastroplasty with a resected stomach in peptic ulcer. // Surgery, 2000, 10, p. 49-55.

Claims (1)

 A method of surgical treatment of patients with pyloric bulbar ulcers complicated by extended pyloric bulbar stenosis consists in performing a distal stomach resection with duodenopilorogastroplasty, characterized in that the stomach stump is formed in the form of a conical tube with a width of 25-30 mm at the end, 8-12 cm long, at the distal end which, departing from the edge of the resection by 35–40 mm, sero-muscular membrane is circularly dissected to the submucosal layer, which is exposed to a width of 8–10 mm, after which the serous-muscular membrane is proximal the cuts are separated to a width of 10-12 mm and wrapped up and hemmed with a free edge to the serous membrane of the stomach stump in a state of moderate tension both in the longitudinal and transverse directions, thus forming a saw-like pulp, then separate knotted sutures passing through the lower edge the formed muscle pulp and the upper edge of the serous-muscular membrane of the gastric stump, while the excess of the mucous-submucous layers of the gastric stump in the form of a duplicate invaginate in the lumen of the distal part of the gastric tube side walls of the gastric transplant, forming a circular valve, then the sero-muscular membrane of the duodenum distal to the scarred bulb is circularly dissected, exposing the submucosal base to a width of 8-10 mm, after which nodal sutures are placed on the posterior semicircle of the anastomosis, passing through the distal and proximal the edge of the serous-muscular membrane of the gastric transplant and the duodenum, then a second row of sutures is applied by the method of two oncoming catgut sutures, stitching the submucosa e layers of the posterior wall of the anastomosis, 1-2 mm from the first row of sutures, then circularly cut off the mucous membrane of the posterior and anterior semicircles of the gastric transplant and duodenum, departing 2 mm from the attached catgut suture, with the remaining catgut sutures, the submucous layers of the right are first sutured, and then the left semicircle of the anastomosis, after which separate nodular serous-muscular sutures are placed on the anterior semicircle of the anastomosis, then along the posterior and anterior walls of the gastric transplant, departing from the gastric duodenoanastomoza 2-3 mm, operate on one longitudinal section laxative sero-muscular layer, not reaching piloropodobnogo bagasse 2-3 mm.

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