RU2257166C1 - Method for surgical treatment of complicated low duodenal ulcers - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: one should dissect ulcerous focus, perform selective proximal vagotomy, cross small intestine being about 10-20 cm below Treitz' ligament, apply distal end through mesocolonic foramen towards the defect in proximal part, remove the defect with intestinal end by "end-to-side" enteroduodenal anastomosis, apply small intestine along vertical, inferior horizontal part of duodenum and initial part of small intestine being below mesenteric root of large intestine, suture in a mesenteric foramen in large intestine. The method enables to keep natural pyloropapillary space, the integrity of nervous-muscular bridge even in one out of intact duodenal walls.

EFFECT: higher efficiency of therapy.

18 dwg, 1 ex

Description

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

Surgery for complications of duodenal ulcer remains an urgent problem, despite the development and implementation of new technologies for both surgical and therapeutic treatment. The development of complications such as bleeding, perforation, stenosis, penetration, gigantic sizes of ulcers continue to be leading in the spectrum of indications for urgent operations, the number of which does not tend to decrease. Such complications often arise after previously performed interventions - suturing a perforated ulcer, suturing a bleeding ulcer, draining operations, pyloroplasty. The choice of the method of operation depends on each specific situation. Both the long course of the disease as a result of ineffective treatment or its absence, and previously performed operations often pose the surgeon with a difficult technological task - restoring the lumen of the duodenal defect after excision of the ulcerative lesion with the pylorus not destroyed in the most physiological way, while preserving natural pyloric papillary diastasis to prevent reflux gastritis. As a result of the ulcerative process or previously performed operations, an anatomical formation such as the duodenal bulb, which provides reservoir and motor function of the duodenum, is lost. Natural pyloric papillary diastasis plays a significant role in protecting the stomach from reflux and the large duodenal papilla (BDS) from acidic gastric contents. Plastic bulb creation is thus an important technological task that prevents the formation of reflux diseases of the stomach - stasis gastritis, erosion and stomach ulcers, gastric cancer, pyloric dysfunction in the form of pylorospasm and pyloric atony, and duodenal papillae in the form of papillitis, stenosis, pancreatitis cholangitis.

Known methods of repairing a bowel wall defect after its excision due to a complicated duodenal ulcer while maintaining an intact pylorus in the form of bridge or segmental duodenoplasty (V.I. Onopriev. Etudes of functional surgery of peptic ulcer. Krasnodar, 1995).

An analogue of the operation can be considered segmental duodenoplasty (Fig. 1, V.I. Onopriev, 1995, Fig. 145), when after excision of the anterior wall that carries a pathological ulcerative process, the scarred side walls of the proximal part of the duodenum are also removed. The narrow bridge on the back wall remains longer than 5-6 cm long and not more than 1 cm wide from the gatekeeper to the BDS. This bridge, as a rule, is well supplied with blood from perforating vessels from the pancreas. The preservation of this bridge is very important to ensure the continuity of the neuro-reflex arc between the stomach and the duodenopancreatobiliary complex. However, the preservation of such a bridge is sometimes technologically difficult due to the low mobility of the pyloric or papillary region due to severe ulcerative periprocess or pancreatic fibrosis, as a result of chronic pancreatitis. The cicatricial inflammatory process in the mesentery of the small intestine at the level of the duodenojejunal junction creates additional technological difficulties for mobilizing the duodenojejunal junction and the first loop of the small intestine. Under these conditions, resection of the extended bridge of the posterior wall is most often used, which leads to the need to perform segmental duodenoplasty, which is undesirable from the physiological point of view of the pyloric papillary anastomosis. In addition, anastomosis under conditions of unresolved tension at the edges of the intestinal wall is dangerous for the development of complications such as failure of sutures, ischemia, and relapse of an ulcer.

Such anastomosis is functionally disadvantageous due to the formation of conditions for reflux gastritis, since a reduction in pyloric papillary distance exacerbates the occurrence of chronic duodenal obstruction.

A bridge-like duodenoplasty was adopted as a prototype of the method (Fig. 2 — V.I. Onopriev, 1975, Fig. 159), in which the rear narrow bridge remains intact, and the mobilization of the pyloric and papillary edges of the intestine ensures adaptation of the intestinal lumen. However, shortening of the pyloric papillary distance also relates to the disadvantages of this method. And besides, it can lead to the formation of diverticulums and deformities at the level of duodenoplasty, diverticulitis, and reflux gastritis.

To eliminate these shortcomings, a method is proposed for small bowel plasty of extensive extended incomplete defects of the proximal part of the duodenum after radical elimination of complicated duodenal ulcer with preservation of the pylorus and natural pyloric papillary diastasis.

Tasks.

1. The least traumatic way to eliminate the extensive defect of the proximal part of the duodenum from the pylorus to the BDS.

2. Create a reservoir - an artificial bulb of the duodenum, ensuring the preservation of the natural pyloric papillary space.

3. To maintain the integrity of the neuromuscular bridge of at least one of the unchanged duodenal wall.

4. To prevent damage and maintain the innervation and blood supply of the pylorus for forced additional mobilization during reduction of the pylorus in case of segmental or bridge-like duodenoplasty.

5. To exclude the stages of mobilization and removal of duodenum from under the root of the mesentery in case of chronic duodenal obstruction in case of inflammatory, cicatricial changes in the root of the mesentery of the small intestine.

The essence of the proposed method is that below the Trentian ligament they cross the small intestine, and its distal end is passed through a window into the mesocolon above the lower horizontal branch of the duodenum to the defect of the proximal part of the intestine and the defect is covered with endobiliary enteroduodenal anastomosis and the intestine is laid along the vertical branch of the duodenum, followed by inter-intestinal anastomosis below the root of the mesentery of the colon.

Indications and contraindications.

Indications for such an operation are:

1. A significant defect in the wall of the proximal part of the duodenum from the pylorus to the BDS.

2. Cicatricial-ulcerative fixation of the gastroduodenal transition.

3. Chronic inductive pancreatitis with the development of inflammatory and cicatricial processes in the intestinal wall, pancreas and omentum.

4. Chronic duodenal obstruction.

Contraindications

1. Suspicion of malignancy of a duodenal ulcer.

2. Sclerosis and fibrosis of the mesentery of the small intestine, preventing the implementation of reconstructive surgery.

3. The extremely serious condition of the patient in the stage of decompensation against the background of peritonitis (perforated ulcer), bleeding (hemorrhagic shock), decompensated stenosis (cachexia with a violation of the electrolyte composition of the blood).

4. Earlier bowel operations.

5. Cancer patients.

Pathomorphological features of the course of complicated duodenal ulcer after previously performed surgical interventions or as a result of a conservative long-term ineffective treatment.

With a widespread longitudinal lesion of the duodenal wall, a surgical situation often arises, as a result of which an intact pylorus and a large and small duodenal papilla remain due to an ulcerative lesion of the intestinal wall during removal of complicated ulcerative destruction of the intestinal wall.

When the pathological field of the ulcer is removed, a longitudinal extensive incomplete (i.e., at least one of the intestinal walls is preserved) defect remains in the intestinal wall. Depending on the preservation of the remaining walls, the following classification of extended extensive incomplete defects of the intestinal wall seems logical:

1. Saved the back wall of the intestine (figure 3).

1.1 The bridge consists of two walls: the rear and the large curvature (figure 4).

1.2 The bridge consists of two walls: the rear and the lesser curvature (figure 5).

1.3 The bridge consists of three walls: the back, the large curvature and the front (Fig.6).

1.4. The bridge consists of three walls: the back, the lesser curvature and the front (Fig. 7).

1.5. The bridge consists of three walls: the back, large and small curvature (Fig. 8).

2. Maintained a large curvature (Fig.9).

2.1 The bridge consists of two walls: a large curvature and the front (figure 10).

2.2 The bridge consists of three walls: large curvature, front wall and small curvature (Fig.11).

3. Saved a little curvature (Fig).

3.1 The bridge consists of two walls: small curvature and the front (Fig.13).

4. The front wall is saved (Fig. 14).

Due to the fact that the blood supply to the duodenal bulb is carried out by vessels flowing from the side of the greater or lesser curvature and partially the posterior wall of the pancreatic vessels, the loss of these walls is dangerous by ischemic disorders along the line of the alleged duodenoplasty. Therefore, it is absolutely contraindicated to leave isolated longitudinal bridges along the anterior wall of the bulb due to the danger of developing insolvency of the sutures of the duodenal wound (Fig. 14).

To eliminate the longitudinal defect of the anterior wall of the duodenum from the pylorus to the level of the papilla (Figs. 3, 4, 5, 9, 12), this method is proposed. Two plastic options can be performed.

Option 1. The mesentery of the small intestine is located medially from the lumen of the duodenum. This option is performed with isolated and combined defects of small curvature of the bulb (figure 3, 4, 9).

Option 2. The mesentery of the small intestine is located laterally from the lumen of the duodenum. This option is used for isolated and combined defects of large curvature of the bulb (figure 5, 12).

Option 1.

The method is as follows. An upper middle laparotomy is performed with a dissection of the left rib-sternal joint and a bypass of the umbilical ring on the right. Using the apparatus of MZ Sigal, traction is performed for the right costal arch. After mobilization and abduction of the round ligament of the liver provide access to the subhepatic space to the right. They open the mantle covering the front surface of the duodenal bulb. After that, the visible borders of the pylorus, the side walls of the bulb are determined. The boundary of the ulcerative infiltrate is determined. A solution of novocaine 0.25% 100 ml is administered paraduodenally and the parietal peritoneum is dissected along the duodenum and mobilized according to Kocher. At the same time, the head of the pancreas, together with the duodenum, is widely separated from the retroperitoneal tissue, the inferior vena cava and the right renal vein. Transverse duodenotomy is performed below the edge of the ulcerative infiltrate. From the lumen, an audit of the ulcer crater, the identification of the pylorus, BDS are performed. A bordering section in the proximal direction along the edge of the ulcerative infiltrate cut off the wall of the duodenum. At the same time, the edges of the scar-changed intestinal wall are excised to its apparently healthy edge.

Visually, in the process of excision, continuous monitoring of the pyloric sphincter border is carried out. The sufficiency of excision of scars is the lack of convergence of the mucous membrane, its pink color, the free extensibility of the serous muscle layer of the intestine, the pyloric fixer. Assess the patency of the BDS by the condition of the external biliary tract and the passage of secretion with finger compression of the gallbladder. In case of doubt about the presence of stricture, the BDS is performed by instrumental bougie through the choledochotomy orifice and papillosciopteroplasty (if it is difficult to pass the bougie less than 5 mm in diameter). When excising cicatricial strata, the most economical excision is performed in the area of the pylorus and BDS. With the formation of an extensive defect in one or more walls of the proximal part of the duodenum, mobilization of the small intestine transplant is performed from the pylorus fixator to the BDS. To do this, in the root of the mesentery of the colon above the descending part of the duodenum, a window is made and through it the distal end of the small intestine is crossed below the ligament of the treitz (at a distance of 10-12 cm). The latter is laid by the mesentery on the front surface of the pancreatic part of the duodenum (Fig. 15). Taking into account the fact that the lumen of the small intestine is smaller than the existing defect in the wall of the duodenum, additionally along the mesenteric edge, the small intestine is dissected into the length of the bridge of the proximal part of the duodenum, followed by a transverse section through the width of the defect.

Restoration of the lumen of the duodenum begins with suturing of the mesenteric angle of the dissected small intestine to the left contour of the bridge with nodules inward, followed by a gradual transition of the suture line to the pyloric and papillary semicircle of the defect (Fig. 16). The seam with nodules inward continues to the top of the lesser curvature of the pyloric and papillary circumference. Then they move to the seam with nodules outward with stepwise sequential matching and stitching of the anterior wall of the pyloric circle with the end section of the intestine to a large curvature of the duodenum at the level of the pylorus.

At the same time, stepwise stitching of the papillary circumference with the cross section of the cut line to the large curvature of the duodenum is performed. Next, the transverse line of sutures passes to the longitudinal lateral wall of the bridge, where the seams are also continued with nodules to the outside, which are sutured with a longitudinal section of the anti-mesenteric edge of the wall of the small intestine along the vertical section line (Fig. 17).

Additionally, fixation by serous-muscular sutures between the vertical branch of the duodenum and small intestine to the window in the mesentery of the colon, along the lower horizontal branch of the duodenum, duodenojejunal transition to the dissected part of the small intestine, where the end-to-side inter-intestinal anastomosis is performed, is performed. The window in the mesentery is then sutured with fixation of the small intestine in it.

After performing a radical elimination of complicated duodenal ulcers and restoring an extensive defect in the proximal part of the lateral small bowel plasty, SPV is performed in a known manner.

Option 2. The method is performed similarly to the above, only the mesentery of the small intestine is located laterally from the lumen of the duodenum (Fig. 18).

The method was tested on 16 patients in the conditions of the Russian Center for Functional Surgical Gastroenterology.

Patient S., 46 years old, was admitted to the clinic with a diagnosis of duodenal ulcer complicated by subcompensated stenosis. Ulcerative history for 20 years. History of repeated seasonal exacerbations. The last exacerbation within 2 months, conservative treatment is ineffective, hospitalized for planned surgical treatment due to severe pain and heaviness in the stomach after eating.

During gastric fluoroscopy, moderate gastric dilatation, cicatricial-ulcerative deformity of the pyloroduodenal junction, stenosis, and ulcer crater along the large curvature of the bulb were detected. During endoscopy, a giant ulcer of large curvature of the duodenum, about 6 cm in diameter, was found in the hematin ulcer crater.

The patient is prepared for surgery and the operation is performed: enteroduodenoplasty. SPV.

The patient underwent an upper middle laparotomy with hardware access correction. An intraoperative study revealed cicatricial and ulcerative deformity of the pyloroduodenal zone. By the large curvature, the crater of a huge ulcer penetrating into the hepatoduodenal ligament is determined. The stomach is moderately enlarged. The pylorus is differentiated by the pyloric vein, which runs in close proximity along the edge of the ulcerative infiltrate. Mobilization of the duodenum together with the head after novocaine blockade into the paraduodenal tissue (0.25% -100 ml) and dissection of the parietal peritoneum, fixing the duodenum to the posterior wall of the abdominal cavity.

Duodenotomy along the lower edge of the ulcerative crater. There is a giant ulcer that occupies the front and side walls of great curvature from the pylorus to the level of the BDS. The ulcer crater 6-3-0.5 cm deep penetrates into the hepatoduodenal ligament. A finger revision of the gatekeeper and BDS was performed from the lumen. The wall of the duodenum is cut off from the ulcer penetration crater. The gatekeeper is partially involved in the edge of the ulcer crater. After excision of the scars, the muscles of the anterior wall of the pylorus are exposed. The lower boundary of the section of the duodenum is in the projection of the BDS.

A bridge was preserved on the back wall and the small curvature of the proximal part of the duodenum with a size of 2-7 cm.In connection with the pronounced periprocess in the gastroduodenal junction, the mobilization of the pyloric zone to bring it to the papillary edge in order to eliminate the intestinal wall defect is dangerous by the violation of the pyloric innervation. In the area of the pancreatic head, fibrosis, infiltration of the greater omentum, which prevents the mobilization and displacement of the descending part of the duodenum to the pyloric edge of the duodenal defect, are noted. To eliminate tension in the suture line and undesirable installation of the pyloric lumen in the projection of the BDS, the first loop of the small intestine was mobilized below the Treitz ligament to preserve natural diastasis between the pylorus and the BDS. Using transillumination at a distance of 10-12 cm from the ligament of Treitz, a mobile loop of the small intestine with a sufficiently long mesentery was selected and the small intestine and its mesentery were crossed. To increase intestinal mobility, the first vascular arch was additionally crossed. The distal edge of the intestine is drawn through a window into the mesocolon above the lower horizontal part of the duodenum to the pyloric department. The mesentery of the intestine is laid on the medial side of the wall of the duodenum. A longitudinal section along the length of the duodenum bridge was made along the mesenteric edge of the end of the small intestine, which is then supplemented by a transverse section along the width of the bridge. The defect in the wall of the duodenum was restored by stitching the medial line of the longitudinal section with the left side of the bridge, then the circumferences of the pyloric and papillary sections with the end and transverse sections of the intestine, respectively, and the subsequent adaptation of the lateral wall of the longitudinal section and the right wall of the bridge of the duodenum were stitched. The small intestine is laid along the duodenum with fixation by serous-muscular sutures to its anterior wall. The window into the mesocolon is sutured to the intestinal wall. Next, the small intestine is laid along the proximal part of the small intestine below the Trent ligament and anastomosis is performed end to side. Then, SPV was performed with mobilization of 6 cm of the abdominal esophagus, the fundus of the stomach within 2-3 short splenic vessels, the lesser curvature of the stomach from the cardia to the angle and the area of entry of the Letarzha nerve paw. Areflux cardia was formed using the fundocardial valve by creating lateral invagination of the esophagus and cardia with the bottom of the stomach and fixing the valve to the esophageal opening of the diaphragm.

The postoperative period was uneventful. The probe in the stomach lasted up to 5 days. The gastrointestinal passage was restored on the 5th day, which allowed to remove the nasogastric gastric tube. The patient was discharged on the 10th day. Examined after 6 months. No complaints. With endoscopy there is a moderate deformation of the gastro-duodenal-intestinal transition. Anastomosis line without signs of inflammation. There are no signs of reflux gastritis. When radiography, the evacuation of contrasted food is portioned for 1.5 hours. During the follow-up examination after a year there are no complaints, he is able-bodied.

Using the method allows to restore the function of the gastrointestinal tract with the radical elimination of complicated duodenal ulcers and to achieve cure for peptic ulcer. Preservation of the stomach, a functioning pylorus, and natural pyloric papillary diastasis ensures the physiological nature of the digestive process, prevents the development of postoperative diseases, and prevents the development of reflux gastritis and post-vagotomy disorders. Thus, the application of this method leads to a reliable recovery of patients, provides a high quality of life.

Claims (1)

A method for surgical treatment of complicated low duodenal ulcers, including excision of a ulcerative lesion and performing selective proximal vagotomy, characterized in that the small intestine is intersected below the Treitz ligament by 10-20 cm and the distal end is passed through a window into the mesocolon above the lower horizontal branch of the duodenum (duodenum) to the defect of the proximal part of the intestine and eliminate the defect by the end of the intestine according to the type of lateral enteroduodenal anastomosis by laying it along the vertical, lower horizontal part of the duodenum and first part of the small intestine with mezhkishechnogo enteric fistula below the root of the mesentery of the colon, and then sutured the window in the mesentery of the colon.

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