RU2201714C2 - Method for making pylorus-saving stomach resection - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out pylorus-saving stomach resection with tubular stomach resection in 2/3 of volume. Blood supply and pylorus innervation is retained. Mucous membrane and submucous base is excised from distal gastric stump. 0.3-0.5 cm of duodenal submucous base is separated. Seromuscular layer is excised from distal gastric tube equal to demucosed pyloric canal in length. Edges of gastric submucous base and duodenal one are end-to-end joined with micro-suture. The second micro-surgical suture row is applied with the distal and proximal portions of the stomach being caught and also end-to-end juxtaposed. EFFECT: enhanced effectiveness in reducing acid production; prevented motor evacuation disorders. 4 dwg

Description

 The invention relates to medicine, in particular to experimental and clinical surgery, and can be used in the treatment of gastric ulcer, cicatricial narrowing of the stomach after a chemical burn, as well as in benign tumors and polyps of the stomach. According to a number of authors (Y.D. Vitebsky, 1986; A.I. Gorbashko, 1987; V.N. Chernyshova et al., 1993; A.A. Shalimov et al., 1996) in 15-85% of patients, having undergone a resection of the stomach, a post-gastro-resection syndrome develops, leading to permanent disability.

 One of the main disadvantages of stomach resection according to the first Billroth method is the occurrence of duodenogastric reflux in 71.1% of patients, which is associated with the removal of the most important antireflux device, which is the gatekeeper of a healthy person.

 Bile reflux has an adverse effect on the cellular structures of the mucous membrane, contributes to the appearance of atrophic gastritis and epithelial dysplasia, thereby increasing the mitotic activity of cells and their tendency to malignancy (Y.D. Vitebsky, 1988; 1991).

 In the prevention of duodenogastric reflux, the technique and technique of the formation of anatomoses play an important role. In this regard, the development of organ-preserving operations on the stomach, which includes pyloric resection (G.S. Toprover, 1960; T. Maki, 1964; A.A. Shalimov, 1965; A.I. Gorbashko, 1983), deserves attention.

 Nevertheless, this operation did not receive sufficient distribution for two reasons: 1) due to the maintenance of a high level of acid formation and the development of peptic ulcers, if the mucous membrane of the antrum was not excised (A. I. Gorbashko, 1986); 2) due to stenosis of the pyloric canal, if the mucous membrane was removed (A.G. Zemlyanoy, 1987).

 A known method of resection of the stomach while preserving the pylorus and replacing the mucosa of the pyloric canal with the mucous membrane of the formed stump of the stomach, proposed by V.F. Naumov (AS USSR 028899. The method of resection of the stomach (VF Naumov. Publ. BI 39, 1978).

 The essence of the method is as follows. When mobilizing the resected part of the stomach, part of the gastrohepatic and gastrocolic ligaments, in which the vessels and nerves pass to the pyloric press, is preserved. A circular sero-muscular layer of the stomach is dissected along the distal and proximal edges of the pyloric pulp. Then the latter is separated from the submucosal layer of the stomach. The duodenum and stomach are crossed along the planned resection lines and the drug is removed, and a stomach stump is formed. From its distal part for 3 cm remove the serous and muscle layer. Gastroduodenal anastomosis is formed by combining three parts that are disconnected from each other: the duodenum, the serous-muscular “sleeve” containing pyloric pulp and gastric stump.

The disadvantages of the method are:
1. The formation of gastroduodenal anastomosis occurs by connecting three disconnected parts (duodenum, pyloric pulp and stump of the stomach), the blood supply to one of which - pyloric pulp - is carried out by two small branches of arterial vessels. Surgical injury or inflammation in the area of the anastomosis can cause vascular thrombosis, impaired blood supply to this zone and failure of the joints of the anastomosis.

 2. When two anastomoses are created by the general surgical method at a close distance from each other, there is a possibility of cicatricial degeneration of the pylorus and the development of functional failure of the pyloric pulp.

 3. When using general surgical technique, there is no exact comparison of tissues homogeneous in histological structure, because all layers of the wall of the stomach, duodenum and serous-muscle pulp of the pylorus are captured in the suture, which leads to the healing of the anastomosis by secondary tension and the functional failure of the pyloric pulp.

 As a prototype, the authors took the method of gastrectomy with preservation of the pylorus proposed by A.G. Zemlyan (1981), in which the line of intersection of the stomach passes 3 cm above the pylorus. After mobilization and removal of part of the stomach, a gastric stump is formed. The mucous membrane of the pyloric valve is not excised. The gastro-gastric anastomosis is superimposed by a twisted catgut suture through all layers, uniformly adapting the stitched sections around the entire circumference. Then a second row of stitches is applied.

Disadvantages:
1. Preservation of the antrum mucosa can maintain a high level of acid formation and cause the development of peptic ulcers of the anastomosis.

 2. There is no exact comparison of homogeneous tissues of stitched organs.

 3. Dense connective and scar tissue formed in the area of the anastomosis prevents the passage of a peristaltic wave in this area, disrupts the motor-evacuation function of the stomach.

 The novelty of the proposed method is the preservation of the pylorus, excision of the submucosal-mucous membrane of the pyloric canal and the replacement of the demucosed area with the submucosal-mucous case of the gastric stump.

 Significant differences of the proposed method are that the stomach is crossed 1.5 cm above the pylorus, the submucosa and the mucous membrane of the pyloric canal are excised. Then from the proximal part of the stomach a tube is formed of large curvature 7-8 cm long, with a diameter at the end equal to the diameter of the distal stump of the stomach (3.0-3.5 cm).

 A serous-muscular case is excised from the distal part of the proximal stump of the stomach for 3-3.5 cm (equal to the length of the demucosated area). Then, the edge of the submucous basis of the gastric stump is compared with the edge of the submucous basis of the duodenum with a butt joint without seizure of the mucous membrane, thus covering the demucous area of the submucous-mucous case of the stomach stump. Next, a second row of microseams is applied, capturing the edges of the serous-muscular cases of the distal and proximal parts of the stomach, juxtaposing them.

 The method is as follows. Outbred dogs of various sexes and weights under thiopental anesthesia performed a mid-median laparotomy. The entire operation was performed under an optical magnification of 6.5 x using microsurgical instruments and a micro-diathermocoagulator.

 The mobilization of the greater curvature of the stomach began from the junction of the right and left gastrointestinal arteries and ended before reaching the pylorus 2-2.5 cm, tying the parietal vessels of the resected part and preserving the main trunks of the gastrointestinal artery. Next, we mobilize vessels of the 2nd-3rd order of small curvature from the suprathoracic zone to the subcardinal region while preserving the main branches of Latarge's nerves. After mobilization of large and small curvature, the boundaries of the resection were outlined. The distal border extends 1.5 cm proximal to the pylorus. At the specified boundary 2 clamps were applied parallel to each other and the walls of the stomach were dissected. 2 parallel clamps in an oblique direction so that their noses did not reach a large curvature of 4.5-5.0 cm (the width of the planned tubular stem) were also imposed on the lesser curvature along the intended line of resection. The stomach intersects between the clamps, after which the remaining small curvature is sutured with a continuous suture that wraps around the unexposed proximal clamp. After suturing, the clamp is removed, the seam is tightened. The second row of sutures is nodular serous-muscular.

 The formation of a tubular gastric stump began from the side of great curvature, departing from the pyloric ring of 8 cm. Two clamps are applied to the section of the stomach from the side of great curvature: one is proximal, the width of the future anastomosis (3.5-4.0 cm), the other - the entire diameter of the stomach.

 Parallel to the large curvature at a distance of 4-5 cm from it, starting from the last seam of the "keel" and to the end of the proximal clamp, we dissect the serous-muscular layers of the anterior and posterior walls of the stomach, exfoliate them from the submucosa in the direction of lesser curvature for 0.5 see. After that, stepwise dissect the submucosal bases of both walls to the right of the line along which the serous-muscular case was dissected, and stitch them with a continuous precision microsurgical suture. The second row - individual serous-muscular nodal sutures with monofilament thread 6/0. The drug is removed. We excise the submucosa and the mucous membrane of the pyloric canal, exfoliate 0.3 cm of the submucosa of the duodenum, carefully performing hemostasis using a diathermocoagulator.

 From the distal part of the stump of the stomach we excise the serous-muscular case for 3.0-3.5 cm, equal to the length of the demucosed portion of the pyloric canal (figure 1).

 Then, the edge of the submucosa of the stomach stump is compared with the edge of the submucosa of the duodenum with a butt weld, thereby closing the demucosed portion of the pyloric section of the submucous-mucous membrane of the stomach (Fig. 2). The mucous membrane in the seam is not captured. Next, impose a second row of microseams, capturing the edges of the serous-muscular cases of the distal and proximal parts of the stomach, juxtaposing them end-to-end (Figs. 3, 4).

 The method was carried out in an experiment in 20 outbred dogs weighing 8-20 kg. In the long term, up to 6 months, the animals are clinically healthy.

 With a fluoroscopy of the stomach, portioned evacuation of the contrast medium from the stomach is noted, occurs in 5-10 and ends in 2-2.5 hours.

 With fibrogastroscopy during the passage of the peristaltic wave in the antrum, the pylorus opens up to 1.0 cm in diameter, taking an oval shape. With the abatement of peristalsis in this part of the stomach, the pylorus closes completely.

 The mucosa of the formed stump of the stomach and the submucosal-mucous case, reduced to the pyloric canal, had the usual color and relief, the connection line of the submucous-mucous cases of the stomach and duodenum is often not detected or is determined only by different heights and directions of the folds.

 When conducting a test for duodenogastric reflux under conditions of intracutaneous hypertension, a water-soluble contrast medium begins to enter the stomach at a pressure of 180-200 mm of water. Art. In a histological examination, epithelialization of anastomoses occurs no later than 5-6 days, healing to the entire depth of the wound in places where the edges of the serous-muscular cases are juxtaposed occurs within 15-17 days without the formation of a rough scar.

Case Studies
1. Protocol 1. Outbred dog weighing 16 kilograms. Under intravenous anesthesia, an upper median laparotomy was performed. Under an optical magnification of 6.5 x using microsurgical instruments, a tubular resection of the stomach was performed with the formation of an adrenal gastro-gastric anastomosis according to the described method. The wound of the anterior abdominal wall is sutured in layers tightly. There were no complications in the postoperative period. Feeding the animal with liquid food began on the 2nd day of the postoperative period. After 6 months, the animal is clinically healthy.

 With FGS, the mucous membrane of the stump of the stomach and the pyloric canal of the usual color, elastic, mobile. The junction of the submucosal mucous membranes of the stomach and duodenum is not determined. The pylorus is fully revealed at the time of passage of the peristaltic wave in the antrum and becomes oval.

 When fluoroscopy, barium from the stump of the stomach begins to enter the duodenum after 5 minutes, complete emptying of the stomach from the contrast occurs after 2 hours.

 A test for duodenogastric reflux was performed: reflux of the contrast agent from the duodenum into the stomach occurs at an intestinal pressure of 250 mm water column. Upon histological examination of the tissue of the serous-muscular layer of the proximal stomach, they uniformly pass into a histologically homogeneous layer of the serous-muscular layer of the distal section of the stomach. At the site of intergrowth of the submucous-mucous membranes of the stomach and duodenum, a delicate connective tissue scar is determined. The submucosa of the submucosal-mucous membrane brought down into the pyloric canal is fused to the muscle layer of the distal stump of the stomach by means of a thin connective tissue layer.

 Protocol 2. Outbred dog weighing 12 kg.

 Under intravenous anesthesia, an upper median laparotomy was performed. Under an optical magnification of 6.5 x, a tubular resection of the stomach was performed according to the described procedure. In the first day of the postoperative period there was a single vomiting. Feeding the animal started on day 2. After 1 month, the animal was withdrawn from the experiment, preliminary functional tests were performed.

 With FGS, the mucous membrane of the stomach, including the reduced to the pyloric canal, is pale pink, elastic, mobile. The pylorus opens at the moment of passage of the peristaltic wave in the antrum, has an oval shape, completely closes after the completion of peristalsis in this department.

 During fluoroscopy, liquid barium from the stomach begins to enter the duodenum after 3 minutes, complete evacuation of contrast from the stomach ends after 2.5 hours.

 When conducting a test for duodenogastric reflux, the reflux of the contrast medium into the stomach occurs with an intestinal pressure of 220 mm water. Art.

 On histograms, the submucosa of the stomach uniformly passes into histologically homogeneous tissues of the submucosa of the duodenum, and the serous-muscular cases of the proximal and distal parts of the stomach are fused without the formation of a rough connective tissue scar.

Claims (1)

 The method of pyloric preservation of the stomach resection by applying a gastro-gastric anastomosis, characterized in that they perform a tubular resection of the stomach in a volume of 2/3, while maintaining blood supply and innervation of the pylorus, dissecting the mucous membrane and submucous membrane from the distal stump, separating 0.3-0.5 cm of the submucosa of the duodenum, from the distal part of the gastric tube, a serous-muscular layer equal to the length of the demucous pyloric canal is excised, the edges of the submucosa of the stomach stump are sewn together and the endo-duodenum with an end-to-end microsuture, a second row of microsurgical sutures is applied, capturing the edges of the distal and proximal parts of the stomach, matching them also with an “end to end”.

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