RU2290882C2 - Method for surgical treatment of gastric and duodenal ulcerous hemorrhages - Google Patents

Abstract

FIELD: medicine, abdominal surgery.

SUBSTANCE: it is necessary to fulfill longitudinal gastrotomy, duodenotomy followed by mucosal revision; one should detect and interrupt ulcerous hemorrhage. After hemostasis it is important to separate mucoso-submucous fragment around the ulcer and implant a microporous titanium nickelide plate into the defect developed supraulcerously. The plate is impregnated with capropher or calcium chloride. The innovation enables to reliably interrupt the hemorrhage in senile patients at high risk of operation, simplify the technique of surgical hemostasis of gastric and duodenal ulcerous hemorrhages, prevent the relapse of ulcerous hemorrhages, decrease the number of post=-surgical complications and lethal results and favors earlier medicinal rehabilitation in such patients.

EFFECT: higher efficiency of therapy.

10 dwg

Description

The invention relates to medicine, namely to abdominal surgery, and can be used for surgical treatment of ulcerative bleeding of the stomach and duodenum in high-risk individuals.

Over the past twenty years, surgeons have begun to review their positions in the treatment of gastric ulcer and duodenal ulcer. Now, fewer resection operations are performed, often complicated by the development of the syndrome of the operated stomach, and disabling patients. They are especially difficult for elderly and senile patients.

In everyday practice, organ-preserving operations are more often used. This direction is especially justified in emergency surgery in elderly people with complicated forms of peptic ulcer in combination with severe concomitant somatic pathology in the stage of subcompensation and decompensation. In such patients, resection of the stomach is life-threatening. It is important that the volume of surgical intervention does not exceed the physiological capabilities of the body. For the treatment of this category of patients, gentle surgeries are more often used: excision of ulcers, methods of plastic closure of a mucosal defect by biological tissues, various options for gastroenteroanastomoses, and others.

So, there is a known method for the surgical treatment of bleeding duodenal ulcers, developed by A.A. Ismailov and R.A. Kuliev "Method for the treatment of bleeding duodenal ulcers", copyright certificate No. 1158171, 1992, which we selected as an analogue.

Its essence is as follows: a longitudinal duodenotomy is performed over an ulcer. A flap of the greater omentum is cut out, then it folds spindle-shaped and is fixed with sutures to the near ulcerous surface. The duodenum wall adjacent to the ulcer is sutured to the inner surface of the intestine along the omentum along its entire length. The duodenal wound is sutured in a T-shape (Figure 1).

In our opinion, the method has significant drawbacks, namely: firstly, a peptic ulcer is not removed, secondly, due to the lysis of the omentum, repeated bleeding is possible, thirdly, vagotomy is not performed, therefore, there is no effect on the pathogenesis of the disease, i.e. prevention of disease recurrence; In addition, suture failure with the development of peritonitis is possible.

There is another method for the treatment of acute bleeding ulcers of the duodenum, which we selected as the protopip "A method for the treatment of gastroduodenal ulcers" (V.V. Grubnik, copyright certificate No. 1507349, 1988).

Its essence is as follows, gastroduodenotomy is performed. Bleeding vessels are stitched with 8-shaped sutures. The bottom of the ulcer is drained, treated with a 70% ethanol solution and filled with an adhesive composition that contains 50-200 UNITS of powdered thrombin per 1 ml of KL-3 glue. A polymerization accelerator is added to the composition. The ulcer is sutured under its bottom (Figure 2) and tightened after the foaming and polymerization of the adhesive begins. During tightening, implantation of glue takes place. The operation ends with a stem vagotomy with pyloroplasty or gastroenterostomy.

The disadvantages of the method are: firstly, the hemostatic effect of powdered thrombin in a polymerized implant is very limited, a relapse of bleeding is possible, secondly, there is no strong connection between the polymer implant and the ulcer surface, migration of the implant from the ulcer is not excluded, and thirdly, with large ulcers this filling can deform the wall of the stomach or duodenum.

Numerous other proposals (in this direction over 100) due to the complexity of the technique of operations, complications in the postoperative period, functional disorders are not widespread. As evidenced by the fact that until now postoperative complications and mortality account for up to 55%. (Bratus V.D., P.D. Fomin, I.L. Lissov et al. Opportunities for improving treatment outcomes in patients with acute ulcerative bleeding. Surgery. - 1992. - No. 9-10; Grigoriev P.Ya., Yakovenko E. . P. Diagnosis and treatment of diseases of the digestive system. - M .: Medicine. 1993).

Based on the analysis of literary information, as well as our own research on the use of implants with the effect of "shape memory" in abdominal surgery, we have developed a method for the surgical treatment of peptic ulcer of the stomach and duodenum at the height of bleeding in the experiment. With its successful implementation, we consider it possible to use the method in elderly patients with severe ulcerative bleeding, when, due to the severity of the condition, a typical surgical intervention is difficult to achieve, where the highest percentage of unsatisfactory results of surgical interventions still remains.

The claimed technical solution implies the implantation of a device from titanium nickelide into a pre-separated submucosal layer above a peptic ulcer, a duodenotomy opening, is sutured according to Heineke-Mikulich, the operation ends with a stem vagotomy. Microporous material due to perfect biocompatibility grows on both sides of the tissues, the mucosa is restored, duodenoplasty according to Heineke-Mikulich protects against stenosis, and stem vagotomy reduces the risk of disease recurrence.

The purpose of the invention is the development of a simple, reliable way to stop ulcerative bleeding of the stomach and duodenum in the elderly with a high risk of surgery.

This goal is achieved by implantation of a microporous (self-fixing) plate into a ulcer defect after preliminary separation of tissues.

Operation Technique.

Initially, it was developed in an experiment on cadaveric material, and then on purebred adult dogs. Its essence is as follows: after appropriate preparation, the animal is given intravenous anesthesia. A laparotomy is performed, a longitudinal gastroduodenotomy is made with an incision up to 3 cm long. On the wall of the stomach or duodenum opposite from the wound, the mucous membrane is irrigated with liquid nitrogen using a cryoapplicator (V.E. Ponter et al. Medical materials and implants with shape memory 1998 ) (Figure 3). When a scab is removed with a tuffer, ulcerative bleeding is created. (S.A.Shalimov, A.P. Radzikhovsky, L.V. Keysevich. Manual for experimental surgery. 1989) The exposure period of cryoapplication is 1.5-2 minutes. As mentioned above, to identical the experiment with ulcerative bleeding, we remove the cryogenic scab. In this case, a bleeding wound is formed - a model of a peptic ulcer (Figure 4). Bleeding is stopped either by coagulation or by ligation of the vessel.

As experience gained, we became convinced that with the diffuse nature of bleeding, there is no need for a thorough stop of bleeding, since the applied self-fixing implant is pressed tightly enough to the tissues, reliably stopping bleeding after 1.5-2 minutes. Additionally, with the aim of reliability of local hemostasis, the porous implant was impregnated with a cold solution of a hemostatic agent. For this we used calcium chloride, caprofer. Bleeding stopped for 1-2 minutes. A porous plate impregnated with a hemostatic solution promotes reliable long-term hemostasis of the ulcer defect.

The next step, out of the “ulcerative” defect, in a circularly sharp and blunt way, the mucous-submucosal layer to the muscle layer is allocated within 3-4 mm (Figure 5). By this time, a titanium nickelide implant is delivered to the operating room in a cooled (0-5 ° C) solution of a sterile solution of calcium chloride, which has the form of a microporous plate (0.3 mm thick, porosity 40-60%). (V.E. Gunter, 1997). The plate is modeled acutely according to the size of the "ulcerative" defect plus 3-4 mm.

The next stage of the operation is the introduction of the implant into the mucosal defect (Fig.6). First, it is inserted between the mucous-submucous membrane that has been separated and laid out outside and the tissues lying deeper on one half of the defect, then on the opposite. In the center, it is slightly pressed to the "ulcer" surface from two sides perpendicular to its plane. Fixation occurs due to surface porosity, roughness, uneven, "tenacious" edges of the plate. Outside, over the implant without tension, the selected mucous-submucous layer is sutured with two sutures. If there is doubt about the reliability of self-fixation, the plate is additionally captured and sutured to the mucous-submucous layer through the holes pre-punched in it.

It should be noted that the self-fixation of titanium nickelide plates has always been reliable, and we resorted to additional fixation in only one case (the first experiment).

The wound of the duodenum is sutured according to Heineke-Mikulich. The operation ends with a stem vagotomy and suturing of the median wound.

Subsequent observations showed that the microporous plate on day 1-5 was covered with a dense blood clot with fibrin filaments, wound hemostasis was stable, no recurrence of bleeding was noted. On the 30th day, the microporous plate completely germinates on both sides of the connective and muscle tissue. A tender scar formed at the site of the simulated ulcerative defect. On the 60th day, the mucosa was completely restored.

We give an experimental observation.

The experiment was conducted on 22 outbred adult dogs at the Central Laboratory of the Tyumen State Medical Academy. There were no deaths from ulcerative bleeding.

The thoroughbred dog "Archie" after preliminary preparation on January 14, 2002 was taken for surgery (operation No. 19). Produced median laparotomy.

Gastrotomy performed. On the mucous membrane of the side of the stomach opposite the incision, a cryoapplicator performed a model of a peptic ulcer according to the method described above with a size of 1.0 cm in diameter (Fig. 7). Exposure to cryotherapy 1.5 minutes. When the scab was removed, a bleeding wound formed, in which an eroded vessel was visible. At the edges of the ulcer in a blunt way, the mucosa 3-4 mm is eccentrically separated. According to the size of the wound, the round section of the microporous plate was cut out from a sterile plate - the workpiece in a sharp way. The resulting device is introduced into the model of the ulcer directly between the "ulcerative defect" and the separated tissues (Fig. 8). After the introduction of the device, and tight pressure against the tissues, the plate was gradually saturated with blood. Bleeding stopped 2 minutes after implantation. Gastrotomy opening sutured according to Heineck-Mikulich. Suturing of the laparotomy wound in layers. The course of the postoperative period without complications. Meals from 2 days. The wound of the anterior abdominal wall healed by the type of primary tension. The animal was removed from the experiment on day 30. At autopsy, it was discovered that the device was sprouted with connective tissue. In place of the formed model of a peptic ulcer, a tender scar was formed (Fig. 9).

In all subsequent animal experiments using microporous plates, we were convinced of the reliability of hemostasis in case of ulcerative bleeding of the stomach and duodenum. None of the animals died from bleeding after surgery. The mucosa of the stomach and duodenum in all cases was fully restored (Figure 10).

Comparison of technical solutions with the prototype established compliance with the novelty criterion, since the proposed method reliably stops ulcerative bleeding, eliminates the ulcer defect by introducing an implant made of microporous titanium nickelide into a preliminary separated into the submucous layer of the stomach and duodenum without excision of the intestinal wall, preserves the natural passage of food through the digestive tract; In order to reduce the acid production of the stomach, stem vagotomy is performed.

When comparing the claimed solution with other methods revealed natural differences.

1. Ulcerative bleeding is stopped by a minimal operation.

2. Plastic ulcer defect is carried out by a microporous plate of titanium nickelide, which has a biological affinity for tissues.

3. Impregnation of a porous plate with a solution of a hemostatic drug helps to achieve reliable stopping of bleeding, which is the key to the success of surgical treatment of ulcerative bleeding, especially in elderly patients.

4. Due to porosity, surface roughness and “tenacity” of the edges, the implant is self-fixed to the tissues.

5. To prevent possible primary migration and fixation reliability in case of large defects, an additional cut of the stomach or duodenal mucosa is sutured over the implant, which together with the device enhances the hemostatic effect and the healing of the ulcer defect.

6. The through germination of the porous plate by the vessels, connective tissue and muscle fibers creates a strong biological framework of the stomach wall or duodenum, which is a reliable prevention of relapse of the ulcer.

7. The main difference of the method lies in the possibility of using the experimental data in clinical practice to stop ulcerative bleeding in elderly and senile patients - the most difficult contingent of patients in abdominal surgery.

Claims (1)

A method of surgical treatment of ulcerative bleeding of the stomach and duodenum, which consists in performing longitudinal gastro-, duodenotomy, revising the mucosa, identifying and stopping ulcerative bleeding, characterized in that after hemostasis, the mucous-submucosal layer around the ulcer is detached, micropores are implanted in the formed defect over the ulcer a titanium plate impregnated with caprofer or calcium chloride.

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