RU2218874C1 - Method for making radical duodenoplastic repair in the cases of duodenal peptic ulcer disease residing on the posterior duodenal bulb body wall and aggravated by penetration into the pancreas - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves locally removing ulcer lesion foci on posterior duodenal bulb body wall. The lateral anterior bulb walls are retained continuous. The posterior duodenal bulb wall is accessed from the greater omentum side via pyloropancreatic ligament. Duodenopancreatic infiltrate is separated. Duodenal wound mouth is adapted after having excised ulcer edges and cicatricial tissues. Serosubmucous sutures are put in over posterior duodenum half-circle. EFFECT: enhanced effectiveness of treatment; retained lateral and anterior bulb walls continuity. 3 dwg

Description

 The present invention relates to medicine, namely to surgical gastroenterology, and can be used in surgery of complicated duodenal ulcers.

 Surgical interventions for penetrating duodenal ulcers constitute one of the most difficult sections of abdominal surgery, due to the anatomical complexity of this zone.

 As an analogue, a method is known for treating duodenal ulcer by excising an ulcer, followed by suturing the edges of the defect (V. I. Onopriev. Segmented duodenoplasty with SPV. Copyright certificate 971286, 1980). The method involves transverse dissection of the anterior wall of the duodenum, mobilization of the posterior wall, excision of pathologically altered tissues, release of the suprabulbar and pyloric portions along the posterior wall, expansion of the pseudo diverticulum wall from the mucosa, restoration of the duodenal ampoule, followed by suturing of the excised edges of the defect.

 The disadvantage of this method is the complete transverse intersection of the duodenum and interruption of intraduodenal vascular and neural connections, followed by a violation of the motor-evacuation functions of the duodenum.

 As a prototype, the technique of organ-preserving surgery for complicated duodenal ulcer is described (Zaitsev V.T., Veligotsky N.N. Organ-preserving operations for bleeding duodenal ulcer. // Clinical Surgery, 1982. 4. - P. 9-13.

 With the localization of an ulcer on the posterior wall of the duodenum and its penetration into the pancreas, V.T. Zaitsev and N.N. Veligodsky developed the method of "circular excision of the ulcerous lesion zone." To this end, a limited mobilization of the duodenal bulb is made along the lesser curvature with the intersection of the right gastric artery and along the greater curvature while maintaining the right gastric artery. In this case, the duodenum intersects along the lower edge of the ulcer. The duodenal stump is treated in an “open way” with the first row of sutures being applied with nodules inward, and then the second row with U-shaped sutures that tightly plug the ulcer crater. Thereby it is excreted beyond the lumen of the digestive apparatus and the ulcer is tightly closed. Subsequently, a circular excision of the duodenal bulb in the area of the ulcer lesion is performed, often involving the pyloric pulp in the scar-ulcer process. The intersection line in most cases runs along the upper edge of the pulp. The termolateral pyloroduodenal anastomosis of the Billroth-1 type is superimposed.

 Assessing the operation of Zaitsev-Veligodsky, it should be noted that only limited mobilization of the duodenal bulb is performed. Due to the extensive removal of the bulb, often together with the pylorus, not only extrapyloric neural connections are violated, but also direct pyloric neural pathways, which violates the coordination function of the pyloric pulp. Thus, the shortcomings of the operation can be distinguished: complete elimination of the bulb, the creation of a blind duodenal stump with tamponade of the crater of the last ulcer, pyloric denervation with a violation of direct pyloroduodenal continuity. In addition, plugging the ulcer crater with the posterior wall of the proximal end of the crossed duodenum leads to postoperative scarring of the duodenal anastomosis zone.

Tasks:
1 - increasing the effectiveness of surgical treatment of complicated penetration of an ulcer of the posterior wall of the duodenal bulb.

 2 - radical removal of complicated penetration of an ulcer of the posterior wall of the duodenal bulb with the preservation of the continuity of the anterior and lateral walls.

 The essence of the invention is that they maintain the continuity of the anterior and lateral walls of the duodenum, provide access to the posterior wall from the greater omentum, through the pyloric pancreatic ligament, separate the duodeno-pancreatic infiltrate and, after excision of the edges of the ulcer and scar tissue, form an anastomosis along the back half the duodenum.

 The method is as follows. After performing the upper middle laparotomy, an intraoperative study of the gastroduodenal transition zone is performed. The prevalence of cicatricial-ulcerative strata along the serous membrane of the duodenum and their fixation to surrounding organs and tissues is revealed. After removal of the cicatricial-inflammatory mantle from the serous membrane, the nature of cicatricial-ulcerative deformity of the duodenum is determined.

 As a rule, isolated ulcerative damage to the posterior wall of the bulb is accompanied by reactive spastic narrowing of the duodenum and a secondary spur is formed at the level of the ulcer - from the front and side walls of the bulb — by doubling the spasmodic walls of the duodenum. Infiltrative-ulcerative circular stenosis causes a reversible deformation of the anterior wall of the bulb in the form of pseudo-diverticulums. When removing the mantle from the spasmodic level of the bulb, the structural safety of the anterior wall and bulb vessels is determined. In the gastrointestinal ligament at the edge of the transverse colon at the level of the antrum, the gland bag is opened (the size of the "window" is at least 10 cm). If necessary, pathological gastro-pancreatic fusion is crossed. Under visual control, a pyloropancreatic ligament is isolated and intersected in an avascular site closer to the posterior wall of the pylorus. After this, it becomes possible to study the posterior wall of the duodenal bulb. The boundaries and severity of cicatricial adhesions in the ulcer area, the depth of penetration are determined.

 Figure 1 (figure 1). Stage of radical duodenoplasty in case of peptic ulcer complicated by penetration into the pancreas.

 1 - stomach; 2 - a large omentum is reserved for the stomach (a “window” in a large omentum); 3 - the gatekeeper; 4 - transverse colon; 5 - pancreas; 6 - an ulcer of the posterior wall of the body of the duodenal bulb.

 In the retroduodenal cellular space outside the area of the pathological focus, the posterior wall of the bulb from the pancreas is separated by tunneling. The edges of the penetration of the ulcer cut off from the pancreas. The ulcer penetration crater remains on the pancreas. The entire bulb is mobilized to the level of the bulboduodenal sphincter, i.e. to the level of intimate vascular fusion with the head of the pancreas. In this case, the gastroduodenal artery is exposed. Large vascular branches running to the posterior wall of the bulb above the bulboduodenal sphincter retain. The edges of the ulcer of the posterior bulb wall are excised and a wide duodenotomy is created, through which the pylorus and the large duodenal papilla are examined. After duodenotomy, the secondary spur of the anterior and lateral walls straightens out. Pancreatic ulcer crater can be located above the level of the gastroduodenal artery, at or below it.

 If the duodenal wound is limited only by the posterior wall, duodenoplasty is performed from the posterior approach (through the “window” in the large omentum).

 The transition of periulcerous infiltration to the lateral walls of the duodenum (greater or lesser curvature) requires combined access. Under bidactile control, through the infiltrated mesentery of the bulb, without damaging the bulbous vessels, a rubber holder is held. Radical excision of the edges of the ulcer and the scar-transformed periulcerous zone is performed.

 An ulcerative crater is cleaned of a layer of necrosis with a Volkman spoon, treated with alcohol, and if necessary, hemostasis is performed. In order to delimit the duodenal wall from the ulcerative crater, it is carried out by omenization with a large omentum flap on the "vascular pedicle", which is involved in the suture line of the posterior bulb wall. The edges of the duodenal wound are previously adapted by serous-submucosal sutures. All seams are laid along the entire line and then tied in stages. At the same time, the periopiloric movable edge is lowered and pulled with sutures to the lower edge, fixed on the pancreas.

 Figure 2 (figure 2). Stage of radical duodenoplasty in case of peptic ulcer complicated by penetration into the pancreas.

 7 - a stomach; 8 - the distal part of the duodenum; 9 - pancreas; 10 - zone of penetration on the pancreas; 11 - duodenotomy opening on the posterior wall of the duodenum, scar tissue is excised, the edges of the duodenum are prepared for suturing; 12 - the gatekeeper.

 Used 1 row nodal external serous-submucosal suture monofilament 4-5 / 0.

 Figure 3 (Fig. 3). Stage of radical duodenoplasty in case of peptic ulcer complicated by penetration into the pancreas.

 13 - stomach; 14 - the gatekeeper; 15 - pancreas; 16 - an anastomosis line is formed along the posterior wall of the duodenal bulb; 17 - zone of penetration on the pancreas.

 By the proposed method, we operated on 16 patients with a duodenal ulcer complicated by penetration into the pancreas and localized along the posterior wall of the duodenum. In 2 patients, penetration was accompanied by arrosive bleeding. The postoperative period in all patients proceeded without complications, the wound healed by primary intention. On the 7-10th day, all patients were discharged for sanatorium or outpatient rehabilitation, while examining the patients a month after radical duodenoplasty, no patients recurred ulcers, and the motor-evacuation function of the duodenum was not impaired.

 EXAMPLE 1

 Patient Ch., 38 years old, peptic ulcer history - 7 years. Hospitalized in a clinic with a duodenal ulcer, accompanied by severe pain. On FGDS - an ulcer of the posterior wall with dimensions of 0.5-0.6-0.2 cm. Due to the ineffectiveness of conservative therapy, the patient is offered surgery in the amount of radical duodenoplasty. During intraoperative examination in the zone of gastroduodenal transition of stenotic deformity, cicatricial retraction in the projection of the ulcer, as is the case with "front" and "side" ulcers, was not detected. Through the “window” in the large omentum, the posterior wall of the duodenum was examined, and the “posterior” ulcer penetrating into the pancreas was revealed. The separation of the wall of the duodenum from the ulcerative crater through the "window" in a large gland. An intraduodenal study was performed: the pylorus and BDS are not involved in the cicatricial inflammatory process. The edges of the ulcer, the scar field are excised, through the “window” in the large omentum, precision monolithic serous-mucous sutures are superimposed on the back wall. Thus, with the localization of the ulcer along the posterior wall of the duodenum, complicated by penetration into the pancreas and the intact anterior semicircle of the duodenum, it was possible to maintain the bridge due to the anterior wall.

 The postoperative period was uneventful, the patient was discharged from the hospital on the 7th day after the operation. During the follow-up examination 1 month after the operation, the motor-evacuation function of the duodenum was not impaired, no data were obtained for the recurrence of the ulcer on the FGDS, there were no signs of inflammation in the anastomotic zone.

 Example 2

 Patient M, 32 g., Ulcerative history - 9 years. He was hospitalized in a clinic with a diagnosis of duodenal ulcer complicated by subcompensated stenosis. When FGDS - in the body area of the bulb along the posterior wall of the duodenum, a ulcerative defect of 0.3-0.2-0.1 cm in size was detected, immediately after the ulcer defect - stenosis of the bulb II-III art. The patient after preoperative preparation was operated on. An intraoperative study in the body area of the duodenal bulb from the side of the serous membrane revealed a zone of segmental spasm. The front wall of the duodenum in the cicatricial process is not involved. The study of the rear wall from the side of the "window" in a large seal. The study revealed a zone of penetration into the pancreas of the “posterior” ulcer. The ulcer was localized along the posterior wall closer to the lesser curvature of the bulb body. In the periulcerous zone, a cicatricial field of the ulcer is expressed, extending to the lesser curvature of the duodenum, pancreas. The wall of the duodenum is stupidly separated from the ulcerative crater, while the lumen of the duodenum is revealed. After separation of the posterior wall with the ulcer from the penetration crater, the duodenum became more mobile. The edges of the ulcer, the cicatricial field of the posterior wall and the large curvature of the bulb are dissected through the “window” in the greater omentum; precision monolithic serous-submucosal sutures are superimposed on the posterior wall. Thus, with the localization of the ulcer along the posterior wall of the duodenum, complicated by penetration into the pancreas and the intact anterior semicircle of the duodenum, it was possible to maintain the bridge due to the anterior wall.

 The postoperative period was uneventful. The postoperative wound healed by primary intention. The seams are removed. The patient was discharged from the hospital for outpatient treatment in satisfactory condition on the 8th day after the operation. During the follow-up examination 1 month after surgery: satisfactory condition, no complaints. On FGDS - signs of recurrence of an ulcer were not detected, in the study of motor-evacuation function of duodenal ulcer pathology was not detected.

 A method for the surgical treatment of complicated ulcers of the posterior wall of the duodenal bulb, which allows preserving its front and side walls, creates optimal conditions for the early and full restoration of the functional activity of the gastroduodenal transition. Using the proposed access to the posterior wall of the bulb reduces the risk of adhesions due to the delimitation of intestinal sutures in the stuffing bag from the free abdominal cavity. All these advantages of the method will reduce the number of complications in the postoperative period and improve the quality of life of patients with duodenal ulcer, preservation of neuromuscular connections in the gastroduodenal junction, reduce motor evacuation disorders and improve the quality of life of patients.

Literature
1. Onopriev V.I. Segmented duodenopadastics with SPV.// Copyright certificate 971286, 1980.

 2. Zaitsev V.T., Veligodsky N.N. Organ-preserving surgery for bleeding duodenal ulcer. // Clinical surgery. 1982. - 4 - S. 9-13.

Claims (1)

The method of radical duodenoplasty in case of duodenal ulcer complicated by penetration into the pancreas with localization of the lesion within the posterior wall of the duodenal bulb, characterized in that the anterior and lateral walls of the duodenum remain continuous, access to the posterior wall from the large wall pyloropancreatic ligament, the duodenopancreatic infiltrate is separated and after excision of the edges of the ulcer and scar tissue of the edge of the duodenal wound, hell Ptýrov sero-submucosal stitches on the back of the semicircle of the duodenum.

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