RU2286096C1 - Method for covering "difficult" duodenal stump at gastric resection by bielrot-ii - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with treating complicated forms of ulcerous gastric and duodenal disease and for the purpose to cover "difficult" duodenal stump one should cut a full-layer gastric fragment out of removed part of greater curvature of stomach upon vascular pedicle of right-hand gastro-omental artery at keeping the whole structure of the wall. One should dissect the excess of mucous membrane upon the full-layer fragment. The fragment prepared for plasty should be moved towards open lumen of duodenal stump and with uninterrupted blanket hemostatic suture one should at first suture gastric and duodenal mucous membranes along the whole perimeter. Then, with interrupted sutures along the whole perimeter it is necessary to suture sero-muscular layers of fragment and duodenum. The innovation suggested enables to prevent the failure of duodenal stump, develop optimal conditions for healing due to good circulation in the full-layer gastric fragment out of right-hand gastro-omental artery.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to surgery, and can be used to treat complicated forms of gastric ulcer and duodenal ulcer.

Reliable shelter of the duodenal stump during resection of the stomach according to Billroth II is the key to a successful course of the postoperative period. Due to the defeat of its ulcerative process, technical difficulties arise when it is sutured due to a deficiency or complete absence of one of the walls of the intestine. Such stumps are conditionally called "difficult", and the processing methods of the duodenal stump are atypical or plastic. A number of authors described modifications of the closure of the duodenal stump with tamponade of the ulcerative crater, differing in the technique of performing minor details. Of the plastic methods, the most famous methods are R. Nissen (Zur Resection des fritzender Duodenal geschwure // Zbl. Chir. - 1933. - N.1. - S.167-172), “cuffs” according to KP Sapozhkov (Two new the method of closing the stump of the duodenum with radical resections of low-sitting and penetrating ulcers of this intestine (the method of “cuffs” and the method of “flap”) // Surgery. - 1951. No. 2. - P.31-37), “snails” S. S. Yudina (Etudes of gastric surgery. - M. - 1955. - 264 p.). Many surgeons use a capsule of the pancreas, a lock of the greater omentum, a round ligament of the liver, and a serous-muscular flap of the stomach for peritonization of the duodenal stump.

V. Pouchet (La plastique chirurgicale illustree. - Paris. - 1927. - 247 p.) Plugged the ulcer with a mucus-muscular flap cut from the front wall of the intestine, stitching it to the distal and proximal edge of the ulcer. The exfoliated serous membrane is sutured to the capsule of the pancreas.

M.E.Steinberg (The surgical treatment of gastroduodenal ulceration. The technique of gastric resection // Surg. Gynec. Obst - 1940. - V.40.- N.3. - P.327-333) recommended for covering the stump, sewn according to Nissen, cut out a demucosal flap from the posterior wall of the pyloric stomach, facing the duodenal stump. A sero-muscular flap is screwed onto the stump and fixed to the anterior and lateral walls.

B.P. Znachkovsky (Covering the duodenal stump with a sero-muscular flap from a resected stomach // Herald of Surgery. - 1962. - No. 5. - P.100-101) to close the duodenal stump, he used a flap cut from the resected part of the stomach. The mucous membrane of the flap was excised, and the mucous membrane of the duodenum was sutured with a continuous twisted catgut suture. Then the duodenum stump was covered with a flap, which was fixed in the center with catgut sutures and silk along the edges to the capsule of the pancreas and serosa of the mesentery of the transverse colon in the form of a “quilted blanket”.

A.P. Mirzoev (Duodenal stasis. - Leningrad. - 1976. - 176 p.) To close the stump of the duodenum, he used a flap cut after removing the mucosa from the back of the stomach above the pyloric pulp.

In urgent surgery, far from always similar methods and techniques can be used. So, for plastic purposes, a large omentum cannot be used for its underdevelopment or cicatricial degeneration. In all the above methods, various gut-closing gut seams passing through all layers of its wall are used. At the same time, creating mechanical tightness, infection through the drainage threads is not ruled out with the formation of a closed "septic" space - an infected cavity between the cut of the duodenal stump and the next row of sutures, which may be a factor in the occurrence of duodenal stump insufficiency. Deficiency of the walls of the duodenal stump does not exclude its excessive skeletonization, ligation of the branches of the gastro-duodenal artery, leading to circulatory disorders, tissue ischemia with the subsequent development of necrosis and insolvency. The use of a pancreatic capsule during suturing of the duodenal stump may contribute to the development of postoperative pancreatitis.

The closest way to the proposed one is the method of Yu.P. Pyankov (The plastic method of suturing the stump of the duodenum during resection of the stomach according to the Billroth-II method in cases of deficiency of its wall. Abstract of dissertation for the degree of candidate of medical sciences. Astrakhan, 1981 P.10-11) Its essence was as follows: a pre-cut serous-muscular flap from the greater curvature of the removed part of the stomach with the feeding leg was applied to the duodenal stitch, which was sutured with a purse-string suture or interrupted silk sutures, due to an equal gastro-omental artery, and 8-10 sutures behind the edges were sutured to the intestinal wall. He completely covered the first row of knotted silk seams.

However, this method has the following disadvantages: this method is used with a sufficient number of walls, which involves the imposition of purse-string or nodal sutures on the stump of the duodenum; to strengthen the duodenal stump, a sero-muscular flap is used, which is more labor-intensive in technical design; a closed cavity remains between the sutured stump and the wall of the serous-muscular flap (formation of hematomas is possible); this technique is not applicable for low duodenal ulcers, especially with no posterior wall.

The aim of the invention is to improve the treatment results of complicated forms of gastric ulcer and duodenal ulcer.

The goal of the invention is achieved by cutting out a full-layer gastric flap from the section of the greater curvature of the stomach with preserving the full wall structure, then an excess of the mucosa is excised on the full-layer flap, and the flap prepared for plastic surgery is moved to the open lumen of the duodenal stump and, first, with continuous continuous hematostatic suture, the entire perimeter of the mucous membranes of the stomach and duodenum, then the serous-muscular layers of the flap and duodenum are sewn along the entire perimeter with interrupted sutures gut.

The proposed method allows to prevent postoperative complications, namely the failure of the duodenal stump. The proposed method is simple in technical execution, less traumatic compared to known methods, allows you to create optimal conditions for healing due to good blood supply to the full-layer flap of the stomach from the right gastro-omental gland.

The essence of the invention is illustrated in figures 1-5, where:

Figure 1 - the right gastro-omental artery in place of its anastomosis with the left intersects and bandages (a). Then a vascular pedicle is formed from the right gastrointestinal artery with ligation of 4-5 of its short branches, suitable to the wall of the stomach (b). Next, oval incisions on the front and back walls of large curvature outline a portion of the gastric flap (c). A scissors or a scalpel through all layers cuts out a full-layer flap of the stomach (g).

Figure 2. - the size of the flap (a) must correspond to the diameter of the duodenal stump (b). Bleeding from the flap is stopped by pressing the vessels or by dressing them. Excess mucosa is excised with scissors (c).

Figure 3 - a full-layer flap (a) moves to the open duodenal stump (b). The continuous mucous hemostatic catgut suture is sewn along the entire perimeter of the mucous membranes of the stomach and duodenum (c).

Figure 4. - serous-muscular layers of the flap (a) and the duodenal stump (b) are sewn with interrupted sutures around the entire perimeter.

Figure 5 is a finished view of the sutured stump of the duodenum with a full-layer flap on the vascular pedicle.

The proposed method was successfully tested in the Astrakhan State Medical Academy during 2003-2004, on 21 dogs, as well as in the clinic - in the surgical department of the Non-governmental Healthcare Institution "Medical Unit" of the city of Astrakhan for 2 patients in 2004.

Below are the results of testing.

Example 1. A dog weighing 10 kg, age 4 years, under general anesthesia was performed upper-median laparotomy. A serous-muscle flap usually began to be cut out after examining the stomach in the area of the part that was to be removed. At the beginning, the anastamosis intersects and bandages between the gastrointestinal arteries, subsequently all the omental branches and part of the proximal branches extending to the stomach, the right gastrointestinal artery intersected and ligated. Then, two semi-oval cuts on the front, and then on the back wall of large curvature, a section of the gastric flap is outlined. A scissors through all layers cut out a full-layer flap from the greater curvature of the stomach (see figure 1). Bleeding on the flap was stopped by pressing the vessel or by dressing them. Excess mucosa was excised with scissors (see figure 2). After mobilization of the stomach and its isolation from the duodenum, a model of intestinal wall deficiency was created by excising a portion of it along the posterior wall. Then the flap was moved to the open lumen of the duodenal stump and the mucous membranes were first sutured with a continuous hemostatic catgut suture (see Fig. 3), and then the serous-muscular layers of the duodenum and full-layer flap along the entire perimeter were sutured (see Fig. 4). A gastric resection was performed in a volume of two thirds of Billroth II.

Example 2. Patient K., 42 years old. / I.B. No. 13279 / was admitted to the surgical department of the NIH MCH on December 21, 2004, 4 hours after the disease with the clinical picture of perforated duodenal ulcer. Duodenal ulcer suffers for 12 years. In an emergency, a laparatomy was performed. During the audit, a perforated ulcer was found on the front wall of the postbulbar part of the duodenum up to 2 cm in diameter with a perforated hole up to 0.5 cm, pronounced phenomena of periduodenitis, perigastritis. In addition, another ulcer of 1.5-2 cm in size and with signs of penetration into the pancreas is determined on the posterior lower wall. Given the operational finding, anamnestic data, it was decided to perform a gastrectomy. The low location of ulcers predetermined significant technical difficulties in the treatment of the duodenal stump. It was decided to resect the stomach with a duodenal stump with a full-thickness flap of large curvature of the stomach on the feeding leg. Before the mobilization of the stomach from the large curvature of the removed part, a full-layer flap was cut with food due to the right gastrointestinal artery 3 × 3 cm in size, which corresponded to the diameter of the duodenal stump. Resection of 2/3 of the stomach was performed according to Billroth II. The full-layer flap was moved to the open lumen of the duodenal stump with suturing with a continuous, hematostatic catgut suture of the mucous flap and duodenal suture, and then the serous-muscular layers of the duodenal stump and full-thickness flap along the entire perimeter with nodal sutures. The operation is completed by bringing the drainage tube to a duodenal stump covered with a full-layer flap. The surgical wound is sutured tightly. In the postoperative period, complications associated with the use of this technique were not observed. In a satisfactory condition, the patient was discharged for outpatient treatment by a surgeon on the 12th day after the operation.

Thus, the proposed method in comparison with the known allows to prevent the development of postoperative complications.

As a result of experimental and clinical studies, it was developed and scientifically substantiated as the most physiologically and functionally optimal method for plastic sheathing of the duodenal stump during Billroth II gastric resection using a full-layer autograft from the wall of the greater curvature of the stomach on the right gastro-omental artery.

Tightness of the stump was carried out by pneumocompression in terms of 1, 7, 14, 30 days, failure of the duodenal stump did not occur in any case. The clinic operated on two patients, there were no postoperative complications.

MmHg. 1 day 7 days 14 days 30 days 320 440 500 520

Histological studies showed that after one year the flap retained its structure. The formed scar in the anastomotic zone is represented by dense interweaving of connective tissue fibers. There are small accumulations of fibroblasts and lymphoid cells. Fibers of connective tissue penetrate into the wall of the stomach and into the wall of the duodenum. In all areas of the scar and adjacent tissues, a large number of vessels of various diameters is noted, which characterizes a satisfactory revascularization of the anastomosis zone (Fig.6).

An immunohistochemical evaluation of the gastric and duodenal mucosa was carried out with the identification of gastric and intestinal antigens as markers for determining the degree of antigenic restructuring of the gastric autograft mucosa implanted in the duodenum.

To determine the qualitative changes in the composition of the protein spectrum of the PSL mucosa of the stomach one year after plastic suturing of the duodenal stump, we obtained acid glycoprotein A Y M from the composition of the dog’s gastric mucosa as a marker. An immunohistochemical study of sections of the stomach PSL after 1 year treated with the gastric antigen showed a clear positive reaction of the gastric PSL mucosa and a negative reaction from the duodenal mucosa, which confirmed the invariability of the protein composition of the gastric PSL mucosa and the absence of its antigenic restructuring (Fig. 7).

An angiographic study of the drugs after 1 year clearly contrasted the vessels of the full-layer flap of the stomach, anastomosing with a large number of vessels of different diameters of the stump of the duodenum (Fig. 8).

Conducted histological, immunohistochemical, angiographic studies, as well as pneumocompression of the stitched stump, suggest that a full-layer stomach flap is a good autograft with complete preservation of the structures of all its layers, the absence of antigenic and protein remodeling of the mucosa of the implanted autograft. Our data indicate sufficient strength and tightness of the sutured dudenal stump, especially with a deficiency of its posterior wall, good adaptation of the edges, without disturbance of angioarchitectonics, and the absence of a closed "septic" space. Due to the abundant blood supply, a full-layer flap is capable of revascularization of the sutured area and contributes to the improvement of reparative processes. The proposed method is technically simple, does not require special training, can be performed by any surgeon with experience in operations on the abdominal organs, both on a planned and emergency basis. The simplicity of technical performance, combined with minimal trauma, will allow this method to be used in the formation of the “difficult” duodenal stump.

Claims (1)

A method of sheltering a “difficult” duodenal stump during Billroth-II gastric resection by using a gastric autograft on the vascular pedicle of the right gastro-omental artery from the removed part of the stomach, characterized in that a full-layer gastric flap is cut out from the section of the large curvature of the stomach while maintaining the full structure of the stomach wall then excess mucosa is excised on a full-layer flap and the flap prepared for plastic surgery is transferred to the open lumen of the duodenal stump and continuous First, the mucous membranes of the stomach and duodenum are sutured along the entire perimeter with a bridal suture, then serous-muscle layers of the flap and duodenum are sewn along the entire perimeter with interrupted sutures.

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