RU2215487C1 - Method for pyloroplasty - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology. SUBSTANCE: the present method deals with surgical treatment of ulcerous disease at localization of scar-ulcerous alterations or ulcer at anterior semicircumference of pyloric sphincter. One should dissect rhomboid-ulcerous substrate. Anterior semicircumference of pyloric sphincter is restored due to carrying out cross-sectional gastroduodenoplasty by suturing the rest triangular fragments of pyloric sphincter at gastric wound edges. Restored anterior semicircumference of pyloric sphincter is invaginated into duodenal lumen by applying pharmacist's ligaturesholders and invaginator. Intestinal pouch is developed out of anterior duodenal wall with serous-muscular sutures. The method in question enables to provide closing function for pyloric sphincter. EFFECT: higher efficiency of pyloroplasty. 5 dwg, 4 ex, 1 tbl

Description

 The invention relates to medicine, namely to surgical gastroenterology, and can be used to restore the evacuation and closure function of the pyloric sphincter in the treatment of complicated forms of gastric ulcer and duodenal ulcer, prevention of duodenogastric reflux and reflux gastritis.

 Known methods of surgical treatment of peptic ulcer disease of pyloric bulbar localization complicated by stenosis, perforation, bleeding, by performing pyloroplasty or combining it with other operations.

 X-ray and endoscopic studies showed that in patients with peptic ulcer all existing methods of pyloroplasty lead to the restoration of the evacuation function of the stomach, but the closure function of the pyloric sphincter is impaired and reflux gastritis develops in 35-64.6% of patients (V.I. Oskretkov et al. ., 1998. Sawmill resection of the stomach in patients with chronic gastroduodenal ulcer. Collection of scientific papers of the All-Russian scientific conference "Actual issues of surgery" Rostov n / D, 1998, p. 210; G. A. Bulgakov, V. A. Kubyshki n, 2001. Modern problems of surgical treatment of uncomplicated peptic ulcer of the duodenum. // Surgery, 2001, 5, p. 31-35).

 In case of complicated ulcers of the anterior semicircle of the pyloric sphincter after distal resection of 2/3 of the stomach, for the prevention of accelerated evacuation from the stomach stump, an operation option with circular immersion of a roller from the tissues along the perimeter of the applied gastroduodenoanastomosis using serous-muscular sutures is used (A.G. Zemlyanoy et al., 1990. A method of treating dumping syndrome after resection according to the first Billroth method. // Vesti, hir., 1990, 9, v. 145, p. 135-137).

 The prototype of the invention is a valve pyloroduodenoplasty method in which a valve is formed by vertical immersion of the folds from its front wall into the lumen of the duodenum after resection of the stomach according to Billroth - I (SF Alikperov, 1994. Valve pyloroduodenoplasty in the treatment of complicated pyloroduodenal ulcers. Abstract. Candidate of medical sciences, M., 1994).

 Studies on the closure function and the incidence of reflux gastritis after these methods of correcting the function of the pylorus or pyloroduodenal junction showed significant disturbances in the closure function and the development of reflux gastritis.

 The objective of the invention is a method of pyloroplasty, providing a radical removal of the ulcer substrate when it is localized in the anterior semicircle of the pyloric sphincter, imparting an effective closure function to the restored pyloric sphincter and preventing duodenogastric reflux.

 The task is achieved in that they produce a diamond-shaped excision of a scarred or with an ulcer of the anterior wall of the pyloric sphincter. Transverse suturing of the wall of the duodenum and stomach with the remaining triangular fragments of the pyloric sphincter, which perform a frame function when restoring the anterior semicircle of the pyloric sphincter, is performed. Applying the second row of serous-muscular sutures, they create a duplicate of the anterior wall of the gastroduodenal junction by invaginating the restored part of the pyloric sphincter into the lumen of the duodenal bulb along its axis in the distal direction and form an intestinal pocket over the restored sphincter anterior wall, which imparts valve properties to the sphincter.

 Figure 1 presents a diagram of a rhomboid excision of a scarred anterior wall of the pyloric sphincter. The dashed line shows the triangular sphincter fragments remaining after excision, indicated by the letter P. The stomach is indicated by F, the duodenum of the DC.

 Figure 2 shows a number of nodal piercing intraluminal sutures superimposed on the front wall of the stomach and duodenum.

 Figure 3 shows a diagram of the imposition of the second row of sutures on the wall of the stomach and duodenum, as well as the location of the invaginator tool, by which the first row of sutures is invaginated into the lumen of the duodenal bulb.

 In FIG. 4 shows the gastroduodenal transition after the imposition of sero-muscular sutures on its invaginated anterior wall.

 In FIG. 5 shows a view of the gastroduodenal transition in the frontal section. Depicted is the anterior semicircle of the pyloric sphincter and intestinal pocket restored by the walls of the stomach and duodenum and intestinal pocket, which imparts valve properties to the restored part of the pyloric sphincter.

 The method is as follows.

 A rhomboid excision is performed of a scarred or with an ulcer of the anterior wall of the pyloric sphincter of the stomach (Fig. 1).

 Perform digital and instrumental revision of the gastroduodenal junction. Its diameter should not be less than 2 cm. Then, stitching nodal sutures from the mucosa are placed on the front wall of the stomach and duodenum, and the remaining triangular fragments of the pyloric sphincter are stitched at the upper and lower edges of the wounds of the stomach (Fig. 2).

 A second row of serous-muscular sutures on the front wall of the gastroduodenal junction creates a duplicate of the walls of these organs and invaginates the wall of the restored defect of the pyloric sphincter in the lumen of the duodenum in the distal direction. To do this, the stomach wall is stitched with three invaginating ligatures 15 mm proximal to the first row of sutures, with the same ligatures the wall of the duodenum is stitched 18 mm distal to the first row of sutures. Above the seam line of the first row of pyroplastics, an invaginator tool is installed (Fig. 3).

 Ligatures in the stomach are fixed in Billroth's clamp. A second clamp is applied to the ligatures in the area of the duodenum and traction is made for these ligatures towards the stomach, while fixing the wall of the duodenum in the area of the pyloroplasty with an invaginator tool that facilitates invagination and provides the necessary depth, since it has a millimeter scale on the rod. Then, ligatures are tied, with the help of which the first row of sutures is invaginated into the lumen of the duodenum. Additionally, on the front wall of the stomach and duodenum impose the required number of sero-muscular sutures (Fig. 4).

 Thus, an intestinal pocket is formed in front of the reconstructed anterior semicircle of the pyloric sphincter, which provides pyloric sphincter valve properties. With an increase in pressure in the intestine, the pyloric sphincter closes, with an increase in pressure in the stomach, it opens (Fig. 5).

Experimental Example
Research was conducted on nine sexually mature dogs weighing from 5 to 10 kg. In 3 animals, a rhomboid excision of the anterior third part of the perimeter of the pyloric sphincter was performed and transverse invagination pyloroplasty was performed.

 Dog B. Weight 8 kg. Upper middle laparotomy was performed under calypsol anesthesia, a diamond-shaped excision of 1/3 of the perimeter of the pyloric sphincter on its anterior wall. In the transverse direction to the axis of the intestine, piercing nodal sutures were placed from the mucosa through all layers of the stomach and duodenum with the remaining triangular fragments of the pyloric sphincter at the upper and lower edges of the wound. On the front wall of the stomach and duodenum at a distance of 13 mm proximal and distal to the first row of sutures, serous-muscular sutures were applied, with the help of which the invaginator instrument invaginated the first gastroduodenal row of sutures into the lumen of the duodenum. These sutures are tied and additionally sero-muscular sutures are applied for the final formation of the intestinal pocket over the invaginated reconstructed anterior lip of the pyloric sphincter.

 Three animals underwent excision of the pyloric sphincter and superimposed termo-terminal gastroduodenoanastomosis with interrupted sutures with immersion of the first row of sutures with the second row of serous-muscular sutures in the form of a roller according to the method of Zemlyanoy A.G. et al., 1990.

 In 3 animals, the pyloric sphincter was excised and the terminal-term gastroduodenoanastomosis was superimposed with interrupted sutures with conventional serous-muscular sutures on the back wall, and submerged serous-muscular sutures were formed on the front wall, forming a valve according to the method of S.F. 1994, Alikperov. In animals after 3 and 6 weeks, X-ray and endoscopic examinations of the stomach and duodenum were performed. The research results are presented in the table.

 The results of experimental studies show that after pyloroplasty by an invagination method, duodenogastric reflux and reflux gastritis was detected in one case at 3 weeks of the experiment. After 6 weeks, these changes were absent.

 With pyloroplasty according to the method of Zemlyanoy A.G. et al. and Alikperova S.F. after 3 weeks, duodenogastric reflux and gastric reflux were determined in all animals. 6 weeks after surgery, duodenogastric reflux was detected equally often in both groups of animals - in 2 animals. Reflux gastritis after 6 weeks of the experiment after pyloroplasty according to the method of Zemlyanoy A.G. et al. revealed in 1 animal, and after pyloroplasty according to the method of Alikperov S.F. - in 2 animals. The results of studies in the second and third groups of animals are explained by the scaling of the structures that recreate the pyloric sphincter into the lumen of the stomach, with an increase in intestinal pressure and the failure of the closure function of these structures of the pyloric sphincter.

 Examples of clinical performance.

 1. Patient K., 53 years old. Medical history 5618/520. He was admitted to the General Surgery Clinic of KSMU on 05.26.2000 with a diagnosis of peptic ulcer, chronic pyloric ulcer complicated by bleeding of the 1st degree. Peptic ulcer suffers for 8 years. Received after 5 hours from the onset of bleeding, manifested by vomiting. In case of emergency FGDS, an ulcerative crater 18 mm in diameter filled with a blood clot was found on the anterior wall of the pyloric sphincter with a transition to the bulb. In the stomach, "coffee grounds." He refused the proposed operation. Homeostatic and antiulcer therapy was performed. 06/07/2000, a relapse of ulcer bleeding of the 3rd degree again occurred. Produced by FGDS. The stomach is filled with blood, blood leakage is observed from under the clot in the ulcer. After FGDS, gas appeared in the subphrenic space, revealed on a panoramic radiograph of the abdominal organs. An emergency laparotomy was performed, chronic pylorobulbar ulcer complicated by bleeding and perforation, local serous peritonitis was detected. Ulcerative infiltrate with a diameter of 2 cm. Subhepatic space sanitized. A diamond-shaped excision was made of the anterior wall of the pyloric sphincter and the wall of the duodenal bulb with ulcerative infiltrate within healthy tissues. Hemostasis. Nodal intraluminal catgut sutures with the capture of the remaining triangular fragments of the pyloric sphincter imposed a number of gastroduodenal sutures. The front wall of the stomach at a distance of 15 mm from the first row of sutures and the wall of the duodenum at a distance of 18 mm from the line of sutures were stitched with three kapron serous-muscle ligatures. An invaginator tool is installed on the wall of the duodenum below the first row of sutures. Traction for ligatures of the duodenum to the side of the stomach and immersion of the duodenal wall by the invaginator, the first row of sutures is invaginated into the lumen of the bulb. After invagination of the first row of gastroduodenal sutures, the anterior wall of the pyloric sphincter was formed. For the formation of the intestinal pocket in front of the invaginated newly formed front part of the pyloric sphincter, the imposition of sero-muscular gastroduodenal sutures was completed. They performed nasoduodenal intubation with a polyvinyl chloride probe. The abdominal cavity was drained in the hypochondrium and iliac region on the right. The postoperative period was uneventful. 06/21/2000 was discharged in satisfactory condition. 09.21.2000 produced by FGDS. There are no data for duodenogastric reflux and reflux gastritis, the pyloric sphincter is hyperimi nated, with a diameter of 15 mm. 09/22/2000. X-ray examination of the stomach and duodenum. The stomach is of normal size. There is an X-ray picture of the usual pyloric sphincter, there is no duodenogastric reflux, portioned evacuation of the contrast mass from the stomach within 1 hour 40 minutes is noted. Endoscopic and x-ray studies 1 year after surgery did not give data for narrowing or insufficiency of the pyloric sphincter. A good motor and evacuation function was found.

 2. Patient T., 67 years old. Case history 6559/618, was admitted to the General Surgery Clinic on 06.24.00, with a diagnosis of peptic ulcer, perforated ulcer of the pyloric sphincter, diffuse fibrinous-purulent peritonitis. Peptic ulcer suffers 10 years. Received 5 hours after perforation. X-ray detected free gas under the right dome of the diaphragm. Operated 1 hour 30 minutes after admission. Under endotracheal anesthesia, a median laparotomy was performed, diffuse fibrinous-purulent peritonitis was detected. The abdominal cavity is sanitized. Cicatricial deformity of the pyloric bulbar region. On the front wall of the pyloric sphincter is a chronic ulcer with an infiltrate of 15 mm and a perforation of 6 mm. Produced a rhomboid excision of ulcerative infiltrate with a 1/2 fragment of the anterior wall of the pyloric sphincter. Hemostasis. Plastic gastroduodenal transition in the transverse direction with stitched intraluminal interrupted sutures with catgut. The second row of serous-muscular nodal sutures with a polysorb was performed invagination of the anterior wall of the restored gastroduodenal junction. Produced nasoduodenal intubation and drainage of the abdominal cavity in the hypochondria and iliac regions. The postoperative period was uneventful. 07.07.00, was discharged in satisfactory condition for outpatient aftercare. 08/06/00, produced FGDS. The stomach is of normal size. The pyloric sphincter is hyperemic, there is no duodenogastric reflux. The phenomena of gastritis are not expressed. 08/07/00, an X-ray examination of the stomach. There is no duodenogastric reflux. A portioned, slightly delayed evacuation of the contrast mass is noted.

 The endoscopic examination on January 25, 01 and the radiological examination on January 1, 01 did not reveal deviations of the motor-evacuation function from normal values.

 3. Patient A., 37 years old. Medical history 6527/608. He was admitted to the General Surgery Clinic on 06.23.00 with a diagnosis of peptic ulcer, perforated duodenal ulcer, diffuse fibrinous-purulent peritonitis. He suffers from peptic ulcer for 5 years. A continuous increased type of acid formation was determined. It was treated occasionally. Perforation 2 hours before admission. Produced by FGDS. The pylorus and bulb are deformed. On the front wall of the ulcer 5x7 mm, perforation 3 mm. 06/23/00, a laparotomy, rhomboid excision of ulcerative infiltrate with a 1/2 fragment of the anterior wall of the pyloric sphincter was performed. Pyloroplasty was performed with invagination of the anterior wall of the restored pyloric sphincter into the lumen of the duodenal bulb. A combined vagotomy (SPV and right-sided stem vagotomy) was performed. The abdominal cavity is drained in the hypochondria and iliac regions. The postoperative period was uneventful. 07/08/00, was discharged in satisfactory condition. 11/20/00 was carried out by FGDS. The stomach is of normal size. Motor-evacuation function is not impaired, intragastric basal secretion according to pH 5.0. 11.21.00, an X-ray examination of the stomach and duodenum revealed the usual x-ray picture of the pyloric sphincter, delayed-dose evacuation of the contrast mass from the stomach.

 The proposed method was applied in 16 patients with a good result.

 Thus, the task is solved by rhomboid excision of the ulcer substrate localized in the anterior semicircle of the pyloric sphincter, restoration of the pyloric sphincter defect due to the walls of the stomach and duodenum, and invagination of the anterior wall of the restored pyloric sphincter into the lumen of the duodenum using the instrument - invaginator with additional fixation of the pocket from the anterior wall of the duodenum of serous-m antiplaque seams providing intussusception. There were no complications associated with the method of invagination pyloroplasty in the early and long-term postoperative period.

Claims (1)

 A method for the surgical treatment of peptic ulcer with scar-ulcerative changes or an ulcer on the anterior semicircle of the pyloric sphincter, comprising a rhomboid excision of the ulcer substrate and performing transverse gastroduodenoplasty, characterized in that after excision of the ulcer substrate, the anterior semicircle of the pyloric sphincter is restored by suturing the duodenal ulcer and the stomach lobe the remaining triangular fragments of the pyloric sphincter at the upper and lower edges of the wound of the stomach and, after which the restored anterior semicircle of the sphincter is invaginated into the lumen of the duodenum with the help of provisional holding ligatures and an invaginator tool and an intestinal pocket is formed from the anterior wall of the duodenum by serous-muscular sutures.

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