RU2241387C1 - Method for radical organ-saving surgical treatment of giant bleeding cardiac ulcers - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should dissect radically a giant bleeding cardiac ulcer, restore the integrity, natural shape and reservoir gastric function due to longitudinal-cross-sectional gastroplasty, replace the edges of gastric defect from the side of its posterior wall, perform T-shaped suture, restore the lesser curvature at the distance against cardiac bagasse being above 0.5 cm with longitudinal suture along the middle line of the lesser curvature; at the distance being below 0.5 cm one should shift longitudinal suture left-hand and upwards onto anterior wall of esophago-gastric passage. One should form the posterior gastric wall in cross-sectional direction. The method enables to keep all gastric departments and its innervation, and save the mechanism of evacuation out of the stomach.

EFFECT: higher efficiency.

3 cl, 2 dwg, 2 ex

Description

The invention relates to medicine, namely to surgical gastroenterology, and can be used in the surgical treatment of gastric ulcer complicated by bleeding.

High ulcerative localizations (cardia and subcardia) are characterized by extensive ulcerative lesions of lesser curvature, due to their size passing to the posterior wall of the stomach, as well as isolated localizations on the posterior wall. Often their sizes exceed 2.0-2.5 cm or more, which completely falls under the concept of giant stomach ulcers. The most common complications are bleeding and penetration, which in the first case requires an immediate and effective method of surgical intervention. The urgency and necessity of choosing an adequate surgical aid at high localizations is usually caused by rather intense bleeding due to the peculiarities of the blood supply to this section of the stomach. Existing views on the choice of the scope of surgical intervention for bleeding from high ulcerative localizations are characterized by a lack of unity. All surgical interventions performed for ulcerative bleeding can be divided into two main groups: radical and palliative. Radical surgical interventions include, first of all, various options for stomach resection, which in some cases cannot be considered justified due to the very high morbidity. In the overwhelming majority of their modifications, resection of the stomach involves the creation of completely aphisiological structures, which significantly increases the risk of both the operation itself and the development of early and late postoperative complications. Organ-preserving surgical interventions used by no means in every case provide for radical removal of the ulcer, and also often destroy important topographic, anatomical, and functional formations. The need to use palliative surgery most often indicates the absence in the arsenal of surgeons of optimal organ-preserving technologies for radical surgical treatment, guaranteeing reliable hemostasis and the very life of a patient with gastrointestinal bleeding with complex high localization of extensive ulcerative lesions, which forces to be limited to suturing or a bleeding vessel in an ulcer, or the same ulcer. It is quite obvious that these surgical interventions cannot guarantee reliable hemostasis and significantly increase the risk of recurrent bleeding both in the early and long-term postoperative periods.

The “Method for the treatment of ulcers of the cardiac section of the stomach” was taken as an analogue (Lubyansky V.G., Ustinov D.N., copyright certificate No. 2159582, 97111775/14, 08.07.1997).

A method of treating an ulcer of the cardiac section of the stomach, including resection of the stomach and laying an esophageal-gastric anastomosis end to side, characterized in that they cut out a stump of the stomach with a conical shape and piercing it along the upper edge, fix the stump of the stomach between the legs of the diaphragm, the esophago-gastric anastomosis is applied at a distance 40-50 cm from the upper edge of the stump of the stomach, with lateral invagination of the esophagus, the front edge of the esophageal opening of the diaphragm is sutured to the stump of the stomach below the suture line of the esophagus of anastomosis.

disadvantages

1) Unreasonable removal of most of the stomach, i.e. its proximal department with functionally important structures: cardiac pulp and fundus of the stomach.

2) Regular damage in this operation of the main gastric and vagus nerves.

3) High risk of pylorospasm.

4) High risk of developing reflux esophagitis due to gastroesophageal reflux.

5) A significant decrease in the reservoir function of the stomach.

The “Method for the treatment of bleeding and perforated stomach ulcers” was taken as a prototype (V.I. Petrov, A.P. Sytnik, V.N. Gorbunov and B.A. Naumov, copyright certificate No. 4354285 / 28-14, 04/15/90 Bull. No. 14).

The aim of the invention is to reduce the duration of the operation and reduce the frequency of post-vagotomy disorders, which is achieved by the fact that when the ulcer is located on the front wall of the stomach, a gastrotomy is performed, 1.5 cm longitudinally departing from the lesser curvature with simultaneous excision of the ulcer. The length of the incision is from the cardia to the angle of the stomach with the preservation of the motor branches of the Latarge nerve. The dissected wall of the stomach is sutured with a two-row suture, then the posterior trunk vagotomy and serotomy are performed in the cardiac section, starting from the upper end of the gastrotomy. When localizing an ulcer on the posterior wall of the stomach, a gastrotomy is performed in this way, the ulcer is sutured with stitching and ligation of bleeding vessels, or excised.

disadvantages

1) The goal itself is completely erroneous, because any time savings are inversely proportional to the quality of the operation.

2) Inadequate choice of antacid surgery option, as stem vagotomy involves the denervation of the antrum and pylorus, as well as the liver and underlying sections of the gastrointestinal tract.

3) The proposed technology does not in every case involve the removal of a bleeding ulcer, which retains the risk of recurrent bleeding.

4) With this technology, it is technically impossible to remove: a) extensive ulcerative defects; b) cardiac ulcers; c) penetrating ulcers.

5) There are no principles of precision in restoring the integrity of the stomach.

Objectives of the invention:

- to provide an increase in the efficiency of surgical treatment of gastric ulcer complicated by bleeding in complex cardiac ulcerative localizations and, therefore, to ensure a higher quality of life for patients with this pathology;

- to develop a comprehensive organ-preserving precision technology for radical surgical treatment of giant bleeding ulcers of the cardial stomach based on a thorough assessment of morphological and functional changes in the entire esophagogastro-pyloroduodenal segment with plastic restoration of the integrity, natural shape and reservoir function of the stomach by longitudinally transverse gastroplasty;

- to develop an organ-preserving technology for the precision mobilization of the lesser curvature of the stomach and the esophageal-gastric transition, combining the provision of adequate operational access to the lesser curvature and posterior wall of the cardial and subcardial parts of the stomach with the basic principles of selective proximal vagotomy;

- provide reliable hemostasis;

- completely remove the ulcer as a source of possible recurrent bleeding;

- save all parts of the stomach and its innervation;

- develop the principles of optimal plastic restoration of the gastric wall and, therefore, the natural shape and function of the stomach;

- exclude gastroesophageal reflux;

- keep the antroduodenal (pyloroduodenal) segment as the most important regulatory mechanism for evacuation from the stomach;

- provide anti-relapse.

The technical essence and novelty of the proposal lies in the fact that a giant bleeding cardiac ulcer is radically dissected, the integrity, natural shape and reservoir function of the stomach are plastically restored by longitudinally transverse gastroplasty by shifting the edges of the stomach defect from the side of its posterior wall with the creation of a T-shaped suture: at a distance from cardiac pulp greater than 0.5 cm, the lesser curvature is restored with a longitudinal seam along the midline of lesser curvature; and at a distance of less than 0.5 cm, the longitudinal suture is proximally displaced to the left and up to the front wall of the esophagus-gastric junction, the posterior wall of the stomach is formed in the transverse direction; providing access to lesser curvature, the cardiac section and the esophageal-gastric transition is performed in the amount of selective proximal vagotomy; when penetrating and spreading inflammatory infiltration to the small omentum to prevent Latarge’s nerve damage, precision mobilization is performed above and below the infiltrate, followed by economical bordering excision of the ulcer and its removal from the lumen of the stomach, the ulcer crater after treatment is left on the small omentum; after gastroplasty, areflux cardia is formed by lateral esophagogastroinvagination with restoration of the esophageal-diaphragmatic, diaphragmatic-fundal ligaments and His angle.

The technology details of the proposed integrated method are shown in the drawings: FIG. 1 and 2.

The method is as follows. The access is carried out by the upper median laparotomy with correction by M.Z.Sigal's early expanders (Sigal M.Z. et al., 1977) and extension of the incision up and to the left of the xiphoid process. This surgical intervention can be divided into five stages sequentially interconnected.

The first step is intraoperative diagnosis. The operation begins with an assessment of the presence of blood in the stomach, small and large intestine to determine the approximate amount of blood loss, which is essential for an adequate anesthetic management. The method of intraoperative diagnosis is very important as a detailed intraoperative study of the entire esophagogastro-pyloroduodenal segment and is a complex of sequentially performed visual, palpation and instrumental studies. The size of the ulcerative infiltrate, its location, the presence of penetration, the degree of prevalence, as well as the ratio of the ulcerative process with important topographic, anatomical and functional structures (cardiac pulp, main gastric nerve, vagus nerves) are assessed. Establishing the exact localization of cicatricial and ulcerative lesions of the stomach relative to the most important topographic and anatomical formations is the most important and necessary condition for performing organ-preserving surgery.

The second stage provides quick access to the lesser curvature and posterior wall of the stomach through the precision mobilization of the lesser omentum and the abdominal esophagus that fully complies with the principles of selective proximal vagotomy, which is achieved by dissecting the peritoneum, skeletoning the esophageal opening of the diaphragm and its left leg by crossing the esophageal-phrenic diaphragmatic, diaphragmatic, diaphragmatic, and diaphragmatic-fundal ligaments.

The vascular and nerve plexus above the lower third of the esophagus and the His angle (i.e., above the esophagus-gastric junction), formed by the branches of the anterior and posterior vaguses and the branches of the ascending esophagus artery, remain in the loose fiber of the small omentum.

After crossing the ligaments, the cardia and the abdominal esophagus are reduced together with fiber, ligamentous apparatus, vaguses and their main branches. At the same time, the esophagus is lengthened, the cardia and His angle are reduced by about 1.5-3.0 cm and the shortened trunks of the vaguses open, which greatly facilitates further work on the esophagus-gastric junction, the posterior extraperitoneal part of the cardia and the bottom of the stomach.

Next, denervation of the anterior wall of the esophago-gastric junction is performed. A flap is formed in front of the mobilized fiber at the apex of the His angle, which is achieved by separating the apex of the small omentum from the wall of the stomach, and after it is fixed on the holder, the small omentum is turned off, the esophagus transition is precision denervated and skeletonized, starting from the His angle. Especially carefully on the wall of the stomach should be allocated the first transverse artery of the stomach with the first branch of the Latarge nerve, the shortest of all its branches. In the small omentum, vagus branches and vessels cut off from the stomach wall remain. The flap is turned away and pulled, while it is almost always possible to control the main gastric branches of the vagus. Turning a small omentum behind the flap, a gap is formed between the last and the wall of the gastroesophageal transition, in which the fiber is bluntly pushed and only the neurovascular bundles are stretched. The length of the selected beam determine the level of its capture.

After crossing the cardiac branches, the mobility of the small omentum flap increases significantly. The main trunk of the vagus with a small omentum is freely retracted and the angle of lesser curvature of the esophageal-gastric junction opens well. The front leaf of the small omentum with vessels and nerves is cut down with the intersection of the first proximal branch of the distal "goose paw" of Latarge's nerve under visual control. The esophagus at the level of the cardia is taken on an elastic holder and taken up and to the left. The middle layer of fiber of the omentum is stretched and the gradual intersection of the latter completes the precision mobilization (denervation) of the esophageal-gastric transition.

Possible technical features of this stage.

1. When performing this stage in patients with extensive ulcerative infiltrates, it is necessary to take into account possible anatomical changes in the area of the esophagus-gastric transition: cardia displacement upward, shortening of the esophagus and trunks of the vaguses, formation of a hiatal hernia, which significantly changes the topographic and anatomical relationships between the terminal branches vagus and creates a risk of damage in this area of the main gastric nerves.

2. In the conditions of penetration, with the spread of inflammatory infiltration to the small omentum to prevent damage to the nerve, Latarge precision mobilization is performed above and below the infiltrate, followed by economical bordering excision of the ulcer and its removal from the lumen of the stomach. The ulcer crater after its treatment is left on a small omentum, the flap of which is already removed together with the ulcer according to the above technology.

The result of this stage is the solution of two fundamental problems: 1) precision denervation of the acid-producing zone with a high acid-suppressing effect against the background of the preserved neurohumoral regulation of the natural evacuation function of the anthropiloroduodenal segment; 2) obtained good access to the lesser curvature, posterior wall of the stomach and esophageal-gastric transition, providing complete freedom of manipulation on the ulcerative infiltrate regardless of its size and location.

The third step is the radical removal of the ulcer along with the ulcerative infiltrate. To do this, an economical fringing gastrotomy is made along the edge of the ulcer infiltrate proximal to the stomach wall and the size and shape of the ulcer defect, signs of ongoing or stopped bleeding are already clarified from the lumen. Then, after providing hemostasis and the necessary aseptic technique, which consists in actively aspirating the possible gastric contents or blood, as well as preventing the gastric contents from entering the abdominal cavity under visual control, the ulcer is completely excised along with the infiltrate within healthy tissues. Scar tissue is excised only in the area of altered tissues, in the presence of an ulcerative, extensive and deep crater penetrating into neighboring organs, the latter is removed from the lumen of the stomach, left in the penetration zone, treated with a Volkman spoon, alcohol and, in some cases, with a bleeding vessel sutured at the bottom of the ulcer. The displacement and expansion of the excision zone or the preservation of scar tissue can lead to deformation of the wall of the stomach, partial ischemia of it and, as a consequence, the inability to achieve the optimal plastic effect of gastroplasty.

The immediate and direct continuation of this stage is the next fourth stage - gastroplasty proper. Its nature and complexity depend on the previous stage. However, the previous stage is no less dependent on gastroplasty, since the use of plastic precision technology when performing gastroplasty allows the most economical excision of scars and ulcers, regardless of the complexity of the resulting geometry of the defect of the stomach wall. The proposed gastroplasty is a typically plastic surgery. A high plastic effect and, as a consequence, restoration of the original shape of the stomach in the absence of deformation and deforming scar tissue is achieved by the use of precision technology, as well as by the need to take into account the direction of muscle fibers, followed by their maximum comparison. All this allows you to avoid local sections of tension and dilatation of the gastric wall in the joints during gastroplasty. It should also be noted the need to take into account the peculiarities of the circulation of the gastric wall in the gastroplasty zone in order to prevent the development of ischemia and, as a consequence, insolvency. The developed technology of plastic restoration of the gastric wall in the conditions of the resulting, as a result of excision of ulcerative infiltrate, extensive defect of the posterior wall and lesser curvature of the stomach (Fig. 1A, p. 1) provides for the formation of a combined precision gastric suture as displaced flaps (Fig. 1A, p. 2), and the back wall of the stomach is sutured in the transverse direction, and the small curvature in the longitudinal. To do this, first assess the distance of the edge of the gastric wound from the cardiac pulp. With a sufficient distance of 0.5 cm (Fig. 1) or more, a muscular-submucosal suture-holder (Fig. 1B, p. 3) is imposed proximally on the lesser curvature strictly along the midline of the right lateral wall of the esophago-gastric transition as a guide for the formation of the most geometrically and anatomically natural bend of the newly created small curvature. A muscle-submucosal suture-holder is also distally applied to the edges of the gastric wound strictly in the middle of the lesser curvature (Fig. 1B, p. 4). Thus, the length of the anterior wall is obtained for the subsequent longitudinal suturing (restoration) of the lesser curvature of the stomach (Fig. 1B, p. 5). The back wall of lesser curvature is formed by shifting the flaps of the edges of the gastric wound from the back wall to the length corresponding to the front wall with two stitch-seams superimposed at appropriate distances on the upper and lower edges of the gastric wound (Fig. 1B, p. 6 and p. 7). Then, with a separate serous-muscular-submucosal suture (Fig. 1 B, p. 8), the failed edges are sutured and a T-shaped configuration is obtained from the round defect of the gastric wall. Next, the gastric wall is sutured in accordance with the created directions: the back wall in the transverse (Fig. 1B, p. 9), small curvature in the longitudinal by individual knotted single-row sutures with monofilament 4-5 / 00 (Fig. 1B, p. 10).

With the immediate proximity of the cardiac pulp to prevent the possible development of impaired patency, the proximal suture-holder is shifted to the left and up to the front wall of the esophageal-gastric transition (Fig. 2A, B, item 11). Further, the technology corresponds to the above (figv).

The fifth stage is the restoration of the closure function of the cardia. The operation is completed by surgical reconstruction of the cardia to restore its valve function. To this end, they create new anatomical relationships between the esophagus, cardia and stomach in the form of an esophagocardiogastric valve using lateral intussusception with restoration of the esophageal-diaphragmatic, diaphragmatic-fundal ligaments and His angle. Selective proximal vagotomy should result in the restoration of the areflux valve function of the cardia in all cases, since the destruction of the ligamentous apparatus of the esophagus and cardia leads to a significant decrease in its function, with the development of cardia failure and reflux esophagitis.

The optimal conditions for the regeneration of adapted tissues of the combined gastric suture are provided by gastrointestinal decompression and washing of the gastric mucosa. Intraoperatively, a nasogastric tube is installed in the stomach to the pyloric sphincter, perforated distally for 10 centimeters. In the first day after the operation, gastric lavage is performed every 3-4 hours in order to evacuate stagnant gastric contents. By the end of the first day, patients are allowed to drink anti-inflammatory decoctions of the herbs of St. John's wort, chamomile, etc. From the second day, the patency of the probe with passive evacuation from the stomach is monitored. During the first 3-5 days, replacement infusion therapy and prophylaxis of pancreatitis are carried out. In most patients, the amount of discharge from the stomach significantly decreased from 3 days, which coincided in terms with the restoration of effective intestinal motility. The nasogastric tube is removed 4-5 days after the evacuation test.

In conditions of radical hemostasis, blood replacement therapy is carried out according to standard indications.

After removing the probe, patients are allowed to take kefir, mucous vegetable soups, cereals. The general rule was a fractional 6-8 single meal in small portions (150-200 ml). By the time of discharge from the hospital (8-12 days), the diet is expanded to table N 15a according to Pevzner.

Prevention of postoperative pancreatitis is carried out in standard mode. The rationality of the anti-enzyme therapy is determined by the indicators of blood amylase in each case. The average duration of prevention is 2-3 days after surgery.

Thanks to the precision technique of a single-row nodular serous-muscular-submucosal suture with the thinnest monofilament suture material, we did not observe suture failure. There were no fatal outcomes.

In the period from 1998 to 2003, this method with good near and long-term results was used in the surgical treatment of 18 patients with gastric ulcer complicated by bleeding from giant cardiac ulcers.

Example 1. Patient K., 45 years old, was admitted to the clinic (1st emergency surgical department of the Krasnodar City Clinical Emergency Hospital) in an emergency with a clinic of profuse gastrointestinal bleeding.

Objectively: the condition is serious, the pulse is 112 beats. in 1 min, A / D 90/60 mm RT. Art. Laboratory: general blood test: red blood cells - 2.2, Hb - 53 g / l.

Emergency fibrogastroduodenoscopy: in the stomach there is altered and unchanged blood, along the lesser curvature in the subcardial section of the stomach ulcer up to 3.0 cm in diameter with a loose “cherry” thrombus in the bottom from which red blood flows.

Diagnosis: gastric ulcer, complicated by ongoing bleeding, hemorrhagic shock II tbsp.

After eliminating hypovolemia and stabilizing central hemodynamics (in the operating room), an emergency operation was performed: longitudinally transverse gastroplasty, selective proximal vagotomy.

Verkhnesomedinaya laparotomy. Correction of access by the Seagal retractors. In the stomach, small and large intestine, blood. By the lesser curvature of the stomach in the cardial and subcardial sections, a 3 × 4 cm ulcerative infiltrate is determined that extends to the pancreas body. The precision mobilization of the abdominal esophagus, esophageal-gastric junction and lesser curvature of the stomach with the intersection of the proximal branch of the distal "goose paw" Latarge nerve was made. An economical gastrotomy was performed along the anterior edge of the ulcerative infiltrate. Revision of an ulcer from the lumen of the stomach. An ulcer crater up to 3 × 2 cm in size is located along the lesser curvature with a transition to the posterior wall of the stomach. No other pathology was detected. The ulcer is partially excised, partially removed from the lumen of the stomach, processed, left on the body of the pancreas. Scar tissue is excised. The suggestive suture-holders are superimposed proximally and distally on the lesser curvature of the stomach. Its posterior wall is formed by the displacement of the flaps of the edges of the gastric wound of the posterior wall of the stomach also by a suggestive suture. The integrity of the stomach was restored by the combined longitudinal-transverse T-shaped suturing of the gastric wall with single-row serous-muscular-submucosal sutures: the posterior wall was sutured in the transverse direction, small curvature in the longitudinal. Cardia areflux was restored by the formation of an esophagocardiogastric valve by lateral intussusception. The abdominal cavity is sutured in layers tightly. Postoperative pathological and histological examination of the drug: chronic progressive gastric ulcer with an arrozed vessel in the bottom.

The patient is at the dispensary, regularly undergoes a follow-up examination in the postoperative period. Another appearance at the dispensary examination 3 years after the operation: no complaints, eats balanced, does not follow a diet, gained 8 kg in weight.

Ultrasound examination: ultrasound signs of diffuse changes in the liver, pancreas.

Fibrogastroduodenoscopy: Condition after gastroplasty with the formation of areflux cardia, superficial gastritis. During X-ray passage of barium through the gastrointestinal tract: portioned evacuation, primary evacuation occurred within 1 minute with satisfactory peristaltic activity in both curvatures from the middle third of the stomach. The time of complete emptying of the stomach from the contrast is 1 h 40 min. There are no signs of gastroesophageal reflux. Conclusion: a condition after gastroplasty with good evacuation function of the stomach. A manometric study of the gastropyloroduodenal complex: antroduodenal coordination is preserved, hypotonic-normokinetic type of antrum motility.

Investigation of gastric secretion: BOD - 1.15 meq / h and MIC - 9.33 meq / h.

Example 2. Patient P., 67 years old, was hospitalized in a clinic (1st emergency surgical department of the Krasnodar City Clinical Hospital for Emergency Medicine) in an emergency with a clinic of gastrointestinal bleeding. Considers herself a patient for about 2 months, when there were pains in the heart. Examination and treatment by a cardiologist without significant effect. About a day ago, while taking cardiological preparations, general weakness appeared, black stool, then repeated three times. Notes a long gastric history with periodic course treatment against the background of seasonal exacerbations due to chronic gastritis.

Objectively: moderate state, pulse 92 beats. in 1 min, A / D 145/95 mm Hg

Laboratory: general blood test: red blood cells 3.05, Hb - 82 g / l. Ultrasound examination: gallstone disease, chronic cholecystitis, chronic pancreatitis.

In case of emergency fibrogastroduodenoscopy: a giant ulcer of the posterior wall of the cardiac section of the stomach was revealed up to 5 cm in diameter with multiple thrombosed vessels in the bottom, unstable hemostasis. Diagnosis: gastric ulcer complicated by bleeding, cholelithiasis, chronic cholecystitis, coronary heart disease, atherosclerotic cardiosclerosis.

After further examination to identify concomitant pathology and the necessary preoperative preparation, given the unstable hemostasis, the patient was operated on urgently. Operation: longitudinally transverse gastroplasty, selective proximal vagotomy, cholecystectomy, drainage of the abdominal cavity. Upper middle laparotomy with hardware access correction. In the large intestine - blood, in the small intestine - traces of blood. An extensive ulcerative infiltrate is determined in the cardiac section of the stomach. Here, through the front wall of the stomach, a deep crater of a giant ulcer of the posterior wall of the stomach was palpated. The precision mobilization of the abdominal esophagus, esophageal-gastric junction and lesser curvature of the stomach with the intersection of the proximal branch of the distal "goose paw" Latarge nerve was made. An economical gastrotomy was performed from the side of lesser curvature along the front edge of the ulcerative infiltrate.

Revision of an ulcer from the lumen of the stomach. The ulcer crater is located strictly along the posterior wall of the cardiac section immediately behind the cardiac sphincter up to 5 cm in diameter with two large thrombosed vessels in the bottom. The ulcer along with the scar-ulcer tissues is completely excised, and the proximal edge of the gastric wound passes directly along the edge of the posterior wall of the cardiac pulp. The suggestive suture-holders are superimposed proximally and distally on the lesser curvature of the stomach. Moreover, the proximal suture of the formed lesser curvature is shifted to the left and up to the front wall of the esophageal-gastric transition to prevent impaired patency of the cardiac pulp. The posterior wall of lesser curvature is formed by the displacement of the flaps of the edges of the gastric wound of the posterior wall of the stomach as well as a suggestive suture. The integrity of the stomach was restored by the combined longitudinal-transverse T-shaped suturing of the gastric wall with single-row serous-muscular-submucosal sutures: the posterior wall was sutured in the transverse direction, small curvature in the longitudinal. Cardia areflux was restored by the formation of an esophagocardiogastric valve by lateral intussusception. In the gall bladder - calculi. Typical cholecystectomy. Drainage to the gallbladder bed. Revision of the abdominal cavity. Layered seams on the wound.

Postoperative pathological and histological examination of drugs: chronic progressive gastric ulcer, chronic cholecystitis.

On examination 1 year after surgery: No complaints. Pain in the heart does not bother. Body weight is stable.

X-ray examination-passage of barium along the gastrointestinal tract: gastric motility is live, of medium depth, free evacuation. After 1.5 hours, the ileum is contrasted. After 4 hours, there are slight traces of barium in the sinus, the colon is contrasted to the lower third of the transverse colon. Conclusion: condition after gastroplasty. Right coloptosis.

FGDS: Catarrhal gastritis. Bulbit. Condition after the formation of areflux cardia.

Ultrasound: a liver of medium size, conventional echostructure. Intra- and extrahepatic bile ducts are not dilated. Gall bladder - removed. Pancreas - normal sizes, scalloped contours, echogenicity increased in the head area. Conclusion: signs of diffuse changes in the pancreas. Investigation of gastric secretion: BOD - 0.78 meq / h and MIC - 6.27 meq / h.

PH metry - in the basal period, acid formation of normal concentration, reduced intensity.

Motility of the gastroduodenal complex: normotonic hypokinetic type of gastric motility.

Medical and social significance. The developed complex organ-preserving technology for radical surgical treatment of gastric ulcer complicated by bleeding from gigantic cardiac ulcers (longitudinally transverse gastroplasty and selective proximal vagotomy) radically removes the pathological focus - ulcer, provides reliable hemostasis and effectively reduces gastric secretion, ensuring anti-relapse, maintaining physiological evacuation stomach and duodenum. This is primarily due to the radical elimination of the cause, i.e. bleeding ulcers, the complete preservation of all departments and structures of the stomach. The use of the original precision technology for plastic restoration of the gastric wall and, therefore, the natural form, reservoir properties and evacuation function of the stomach, will significantly improve the immediate and long-term results of treatment of patients with high bleeding stomach ulcers, reduce the number of postoperative complications and mortality, and will allow to maintain and restore working capacity.

A significant increase in the quality of their life will have a socio-economic effect, as it will lead to a decrease in the disability of patients in this group, which will allow them to return to active work.

Claims (4)

1. A method of radical organ-preserving surgical treatment of giant bleeding cardiac ulcers, including vagotomy, characterized in that the giant bleeding cardiac ulcer is excised radically, the integrity, natural shape and reservoir function of the stomach are plastically restored longitudinally-transverse gastroplasty by shifting the edges of the stomach defect from the side of its posterior wall with the creation of a T-shaped seam: when the distance from the cardiac pulp is more than 0.5 cm, the small curvature is restored with a longitudinal seam along edney line of small curvature; and at a distance of less than 0.5 cm, the longitudinal suture is proximally displaced left and up to the front wall of the esophagus-gastric junction, the posterior wall of the stomach is formed in the transverse direction. 2. The method according to claim 1, characterized in that providing access to lesser curvature, the cardiac section and the esophageal-gastric transition is performed in the amount of selective proximal vagotomy. 3. The method according to claim 1, characterized in that when penetrating and spreading inflammatory infiltration to the small omentum to prevent Latarge’s nerve damage, precision mobilization is performed above and below the infiltrate, followed by economical bordering excision of the ulcer and its removal from the lumen of the stomach, ulcer crater after it treatments are left on the small oil seal. 4. The method according to claim 1, characterized in that after performing gastroplasty, areflux cardia is formed by lateral esophagogastrointestinal invasion with restoration of the esophageal-diaphragmatic, diaphragmatic-fundal ligaments and His angle.

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