RU2312609C1 - Method for surgical treatment of complicated low duodenal ulcers at lesion of major and minor duodenal papillae - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: at no destruction of major and minor duodenal papillae they should be isolated out of cicatricial-ulcerous focus, the edges of posterior wall of duodenal distal end should be sutured along the circumference of major duodenal papilla and further till the removal of diastasis with duodenal proximal end. One should implant minor duodenal papilla into posterior wall of duodenal anastomosis, longitudinally dissect anterior wall of duodenal distal stump at length that corresponds to lumen's reconstruction, form anterior-lateral walls of anastomosis with shifted fragments of mobilized distal duodenal department. In case of destruction of major and minor duodenal papillae out of cicatricial-ulcerous focus one should isolate terminal departments of Wirsung's, Santorini's and common bile ducts. One should suture the edges of posterior wall of duodenal distal department along the circumference of Wirsung's and common bile ducts and further till the removal of diastasis with duodenal proximal end. One should implant Santorini's duct into posterior wall of duodenal anastomosis, longitudinally dissect anterior wall of duodenal distal stump at length that corresponds to lumen's reconstruction, form anterior-lateral wall of anastomosis with shifted fragments of mobilized distal duodenal end. The innovation enables to radically heal the complicated ulcer, reconstruct anatomical structure of duodenum, major and minor duodenal papillae, improve functional results of interference, prevent the development of pancreonecrosis and failure of sutures in post-surgical period.

EFFECT: higher efficiency of therapy.

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Description

The present invention relates to medicine, namely to surgical gastroenterology, and can be used in surgery of complicated low duodenal ulcers (duodenal ulcer). The proposed surgical treatment technology is designed for the level of a specialized surgical gastroenterological hospital.

According to domestic authors, duodenal ulcer is found in approximately 12-18% of the adult population (Komarov F.I., 1995), and low ulcers according to the literature are found in 3-8% of cases.

Surgical treatment of complicated duodenal ulcer continues to be a vital issue in general surgery, despite the success achieved in conservative treatment. Papillary or postbulbar duodenal ulcers are a relatively rare but formidable complication of peptic ulcer.

In the surgical treatment of low duodenal ulcers, the percentage of postoperative complications and deaths due to iatrogenic damage to the common bile duct and pancreatic ducts remains high.

A large number of so-called organ-preserving technologies, in the scope of vagotomy and drainage operations at low ulcers, are performed either without intervention on the ulcer itself, or with the bleeding ulcer being stitched and the ulcer crater plugged with the wall of the stomach or duodenum, which can cause complications such as pancreatitis, pancreatic necrosis , inconsistency of sutures and peritonitis.

The main disadvantage of most known methods of surgical treatment of complicated periapical ulcers is the lack of guaranteed technology for protecting the ducts from iatrogenic damage, compression, flashing, as they do not eliminate stasis, hypertension, do not prevent the development of stricture of the ducts, and do not guarantee hemostasis. This is the reason for the development in the early postoperative period of acute pancreatitis, relapse of bleeding, and in the long term - cicatricial stricture of the ducts.

A known method of surgical treatment of low complicated by penetration and bleeding of giant duodenal ulcers, proposed Onopriev V.I. and co-authors (patent for the invention No. 2259169 dated 05.03.2004). This method allows you to perform radical duodenoplasty with plastic surgery of the Santorini duct, exposed or damaged in the pancreas crater penetrating ulcer. A segment of the duodenum involved in the ulcer process is resected, the end of the santorin duct is isolated in the ulcer crater, the crater is omentoplasty and a duct is formed through a puncture in the gland, then with a duct width of no more than 2 mm, a duct is formed through a puncture of the posterior wall of the proximal or distal duodenal stump , fix it with sutures to the edges of the puncture in the mucous membrane with free drooping of his stump into the lumen of the intestine and perform radical duodenoplasty, and with a duct width of 3-5 mm Sew in the back line of the duodenal anastomosis or in the back line of the sutures of the duodenal wound when performing radical duodenoplasty.

The disadvantage of this method is the lack of the ability to perform duodenoplasty with severe scar and ulcerative deformities of the duodenal bulb with lesions of both small and large duodenal papillae.

As the closest analogue, the method of surgical treatment of complicated periapical duodenal ulcers proposed by V. Onopriev was adopted. and Rovov A.A. (patent for the invention No. 1674812 of 04.16.1993). This method allows you to perform radical duodenoplasty in the immediate vicinity of the large duodenal papilla (BDS).

The method is as follows.

Resection of the segment of the duodenum involved in the ulcer process is performed, mobilization of the posterior wall of the distal end is performed, bypassing the site of location of the BDS. The back wall from the papilla is sutured in the longitudinal direction for 1.5-2.0 cm and a duodeno-duodenal end-to-end anastomosis is applied.

The disadvantage of this method is the possibility of the development of postoperative pancreatitis as a result of the development of edema of the duodenal mucosa, especially if the patient had stenotic papillitis before the operation, and this method also does not allow radical duodenoplasty to be performed during inter-papillary localization of complicated ulcers.

Objectives: To improve the results of treatment of complicated low periapical ulcer, reduce mortality and postoperative complications, reduce the treatment time for patients with this pathology, improve the quality of life and reduce the period of disability and disability.

The technical result of the proposed method is that by performing radical duodenoplasty with complicated low duodenal ulcer with lesions of the large and small duodenal papillae by the claimed method, the possibility is achieved not only of radical elimination of the complicated duodenal ulcer with this complex variant of cicatricial ulcer when other types of duodenoplasty technologically not applicable, but also completely restore the anatomical structure of the duodenum , large and small duodenal papillae, the terminal part of the common bile duct, which can significantly improve the functional results of surgical interventions for complicated periopapillary duodenal ulcers, prevent the development of pancreatitis and pancreatic necrosis in the postoperative period, and avoid the development of failure of sutures of the duodenal wound.

The essence of the invention is that small and large duodenal papillae are isolated from the cicatricial and ulcerative lesion, or, if they are destroyed, the terminal sections of the Wirsung, Santorini and common bile ducts are sutured, the edges of the posterior wall of the distal end of the duodenum are sewn around the circumference of the large duodenal papilla (Wirsung and bile duct), until diastasis with the proximal end of the duodenum is eliminated, after which the small duodenal papilla (or santorin duct) is implanted into the posterior wall of the duodenum anastomosis ceiling elements, while the antero-lateral wall of the anastomosis formed offset flaps mobilized distal end of the duodenum, which if necessary is dissected longitudinally along the front wall for matching the diameter of the intestinal lumen. The execution of the method is additionally illustrated in figures 1-6, where (figure 1): 1 - gastroduodenal junction, 2 - cicatricial and ulcerative deformity of the duodenum, 3 - head of the pancreas, 4 - lower contour of the post ulcerated scar of the anterior wall of the duodenum; (figure 2): 5 - small duodenal papilla, 6 - large duodenal papilla, 7 - perforating vessel, 8 - terminal section of the Wirsung duct, 9 - terminal section of the Santorini duct, 10 - terminal section of the common bile duct; (Fig.3): 11 - the proximal edge of the duodenal wall, 12 - the distal edge of the intestinal wall, 13 - the edges of the posterior wall of the distal end of the duodenum stitched around the circumference of the large duodenal papilla; (figure 4): 14 is a line of seams of the rear wall of the distal end; 15 - santorinium duct implanted in the posterior wall of the duodenum; 16 - longitudinally dissected anterior wall of the distal end of the duodenum; (figure 5): 17 - displaced flaps of the mobilized distal end; (Fig.6): 18 - line duodeno-duodenal anastomosis "end to end".

The method is as follows:

Under general anesthesia, a mid-median laparotomy is performed with hardware correction of the wound aperture by Sigal-Kabanov's conservatives down and to the right.

An intraoperative study of the gastro-duodenal transition zone is carried out. 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 in paragraph 2.

Under the duodenum and around the head of the pancreas, 200.0 ml of a 0.25% solution of novocaine is administered. The duodenum together with the head of the pancreas of item 3 is mobilized with the dissection of the paraduodenal parietal peritoneum along the upper and descending parts. Mobilization of the mesentery root of the transverse colon and the right hepatic bend of the colon is performed. From the duodenum remove cicatricial adhesions and perform transverse duodenotomy of the anterior wall in the area of the ulcer (post ulcerous scar) along its lower contour of paragraph 4. Revision is continued through the lumen of the intestine. Establish the exact localization of the ulcer, its size, the degree of penetration, the state of the pylorus, the relationship of the ulcer with the large and small duodenal papillae p. 3, 6 and their condition. The duodenum in the ulcer zone from the side of the side walls is mobilized parietally. At the same level, the posterior wall and the segment of the intestine carrying the ulcer are mobilized, resected, leaving a ulcerative crater of penetrating ulcer on the head of the pancreas. Phased mobilization is accompanied by precision ligation of the perforating vessels of claim 7, emanating from pancreatic tissue. If a deep ulcer of a small and a large duodenal papilla is found in the crater, they are revised, and when they are destroyed, the terminal sections of the Wirsung, Santorini and common bile ducts are identified in clauses 8, 9, 10. The proximal and distal edges of the intestinal wall are mobilized and scars are removed. 11, 12, while in all cases, the lumen of the ducts is pre-drained with thin microdrainage with perforated holes, which allows more confident to continue the stage of preparation of the intestinal edge from the ulcer crater with the removal of inflammatory-changed Yenok duodenal wound and excludes damage of scar tissues pancreatic duct. In this case, the distal border of the resection passes between the large and small duodenal papillae. The crater of the ulcer is scraped with a Volkman spoon with the removal of tissue decay and granulation elements to the scar layer and pancreas. The free omentum flap is cut out on the vascular pedicle, ulcers are laid on the bottom of the crater and fixed to the edges of the crater with separate sutures. Then, the edges of the posterior wall of the distal end of the duodenum are sutured with absorbable suture material (6/0-PDS) on an atraumatic needle around the circumference of the large duodenal papilla, or Wirsung and common bile ducts of item 13, until diastasis with the proximal end of the duodenum is eliminated. When they are tied with knots inward, a new posterior wall is formed proximal to the papilla, covering the crater of the penetrating ulcer of item 14. The edge of this wall is displaced by 1.5-2.0 cm to the proximal stump of the intestine, and therefore the comparison of the walls of the intestine on the back wall is greatly simplified and pyloric papillary diastasis is eliminated. After that, a small duodenal papilla (or Santorinia duct) is implanted in the posterior wall of the duodenal anastomosis of clause 15. If, during longitudinal suturing of the posterior wall, narrowing of the lumen of the stump occurred, then longitudinal dissection of its anterior wall is performed for the period necessary to restore the lumen of clause 16, and the front-side walls are formed by displaced flaps of the mobilized distal end of the duodenum of clause 17. For good mobility of the descending section of the duodenum, mobilization of the lower horizontal branch of the duodenum is performed, which, if necessary, is supplemented by the intersection of the Tereitz ligament, mobilization of the root of the mesentery of the small intestine, rotation of the duodenum and giving it a downward position on the right side channel to the right of the root of the mesentery of the small intestine. After that, the end-to-end duodeno-duodenal anastomosis with the proximal stump of the duodenum with a single-row sero-muscular-submucosal suture without suturing the mucous membrane with a resorbable suture 6/0 on an atraumatic needle, p. 18, is already quite freely formed. From above, the line of a single-row seam is additionally peritonized with an omentum. In the postoperative period, constant nasogastric intubation, antibiotic therapy, and prophylaxis of pancreatitis with gastric and pancreatic secretion blockers are performed. Subsequently, selective proximal vagotomy is performed to prevent ulceration.

Example. Patient F., 59 years old. IB No. 468, was admitted to the clinic for planned surgical treatment for a long recurrent course of duodenal ulcer complicated by decompensated stenosis. On fibrogastroduodenoscopy (FGDS) there is an ulcer of the posterior wall, 2.5 cm in size. A history of repeated episodes of gastrointestinal bleeding.

Under general anesthesia, the patient underwent an upper median laparotomy with intersection and dislocation of the right rib-sternal joint and bypass of the navel on the left. By installing a retractor M.Z.Sigal (M.Z.Sigal et al., 1977) in the right hypochondrium, traction was provided for the right costal arch, which created ideal access to the head of the pancreas and duodenum.

An intraoperative study of the gastro-duodenal transition zone is performed. Mobilization of the entire right half of the colon with the intersection of the right hepato-colonic ligament with the displacement of the right part of the colon into the right ileal region was performed in stages with precision. The root of the mesentery of the colon is gradually mobilized and open access to the entire horseshoe of the duodenum with the head of the pancreas.

The pancreatoduodenal complex was mobilized to the inferior vena cava, i.e. together with paraduodenal fiber, which is removed from the inferior vena cava and which is completely skeletonized, i.e. naked.

The anatomical preparation, i.e. the release of the bulb, the bulboduodenal junction, the descending section of the duodenum from the ulcerative periphery of the mantle and from communication with surrounding tissues.

Performed transverse duodenotomy, i.e. a transverse section of the anterior wall from large to small curvature of the duodenum, corresponding to the level of the distal edge of the crater penetrating ulcers.

The incision corresponded to the lower edge of the ulcerative stenotic deformity of the duodenal wall. The pylorus was identified by external anatomical landmarks on the serous membrane of the gastro-duodenal junction (pyloric vasculature), as well as by intraduodenal palpation examination.

An objective criterion for a low duodenal ulcer was the presence of transverse folds of the duodenal mucosa below the distal edge of the ulcer crater.

Before proceeding with the mobilization of the wall of the duodenum from the distal edge of the ulcer crater, a study of the ulcer crater was conducted.

An audit revealed a giant penetrating ulcer of the posterior wall measuring 2.5 cm in diameter and a crater depth of 1.0 cm, involving small and large duodenal papillae. During compression of the gallbladder, bile flowed freely into the lumen of the duodenum. Dimensions of the common bile duct 5 mm, no biliary hypertension.

The lumens of the ducts were pre-drained with thin microdrainage with perforated openings, which allows more confidently continuing the stage of preparation of the intestinal edge from the ulcer crater with removal of the inflammatory-altered walls of the duodenal wound and eliminates damage to the scar tissue of the pancreatic duct. The precision preparation mobilized the duodenal wall from scarring of the ulcer crater, excised pathological tissues with the preservation of 0.5 cm of the healthy duodenal wall mobilized in the immediate vicinity of the pancreas. Moreover, the mucous membrane of the duodenum is preserved in the region of the large duodenal papilla for 5 mm in the proximal direction. The ulcer crater was scraped with removal of tissue decay and granulation elements to the scar layer and pancreas, followed by treatment with alcohol. Phased mobilization was accompanied by precision ligation of perforating vessels emanating from pancreatic tissue. Precision preparation of the Santorini duct allowed to move away from the edge of the penetration crater, remove scar tissue, maintain the intestinal wall and mobilize in a volume of 0.5 cm from the edge of the intestinal incision. The gatekeeper was 3-4 cm from the section line. To eliminate the tension of the suture line of the posterior wall and for good mobility of the descending duodenal ulcer, the lower horizontal branch of the duodenum was mobilized with the intersection of the Tereitz ligament, mobilization of the root of the mesentery of the small intestine, the rotation of the duodenum and giving it a downward position on the right side channel to the right of the root of the mesentery of the small intestine.

The free omentum flap was cut out on the vascular pedicle, laid on the bottom of the crater and fixed with separate sutures to the edges of the crater. Then, the edges of the posterior wall of the distal end of the duodenum were sutured with absorbable suture material (6/0-PDS) on an atraumatic needle around the circumference of the large duodenal papilla (Wirsung and common bile duct), until diastasis with the proximal end of the duodenum and small duodenal papilla was removed. When they were tied with knots inward, a new posterior wall was formed proximal to the papilla, covering the crater of the penetrating ulcer. Internal drainage of the ducts contributed to their more distinct identification both in the gland tissue and in the wall of the duodenum. The edge of this wall is displaced by 1.5-2.0 cm to the proximal stump of the intestine, and therefore the comparison of the walls of the intestine on the back wall is greatly simplified and pyloric papillary diastasis is eliminated. After that, a small duodenal papilla (or Santorinia duct) is implanted in the posterior wall of the duodenal anastomosis, and the antero-lateral walls are formed by displaced flaps of the mobilized distal end of the duodenum. If, during longitudinal suturing of the posterior wall, a narrowing of the lumen of the stump occurred, then a longitudinal dissection of its anterior wall is performed for the length necessary to restore the lumen.

The anterior wall of the duodenal anastomosis is sutured with a single-row sero-muscular-submucosal suture with nodules outwards with additional peritonization of the suture line with the omentum. To prevent the development of edema of the BDS, microcholecystostomy was performed.

The postoperative period was uneventful. Transnasal drainage in the stomach prevented gastric stasis for 5 days. During these days, the patient was in the intensive care and resuscitation department, where he received treatment aimed at replenishing physiological and pathological losses. Antibacterial therapy was also conducted to prevent infectious complications and pancreatitis.

On the 7th day fistulocholecystography was performed, the common bile duct passes, contrast in the duodenum comes, on the 8th day the drainage from the gallbladder is removed. On day 30 after surgery, drainage in the ducts is removed. The patient was examined after 3 months, recurrence of ulcers was not detected. Helicobacter pylori treatment was performed. After a year, the patient is healthy, there are no complaints, the ability to work is preserved, the quality of life is high.

The patient was examined after a month. No complaints. There was no recurrence of an ulcer on FGDS. After 2 months, with clinical remission of peptic ulcer, selective proximal vagotomy was performed to prevent ulceration.

When examined after 1 year, the patient is able to work, does not show complaints, according to the results of a comprehensive examination, including questionnaires, the patient's condition corresponds to a high level of quality of life, i.e. complete preservation of health is achieved.

The proposed method allows to improve the functional results of surgical interventions for complicated periapical duodenal ulcers, to prevent the development of pancreatitis and pancreatic necrosis, to avoid the development of failure of sutures of the duodenal wound.

The method is recommended for practical use.

Medical and social effectiveness: the proposed method for the surgical treatment of complicated low duodenal ulcers with lesions of the small and large duodenal papillae can significantly improve the results of treatment of complex localization of duodenal ulcers and is characterized by a complete cure for peptic ulcer and virtually no formidable complications in both early and late postoperative period. Using the method allows to achieve the highest possible quality of life for patients, to fully restore professional ability to work, since the operation is not disabling, but only restoring in nature, which is of great socio-economic importance.

Claims (1)

A method for surgical treatment of complicated low duodenal ulcers with lesions of the large and small duodenal papillae, including radical excision of the segment of the duodenum within the scar-ulcer lesion followed by terminal duodenoplasty, characterized in that in the absence of destruction of the small and large duodenal papillae, they are isolated from the scar-i foci, stitch the edges of the posterior wall of the distal end of the duodenum around the circumference of the large duodenal papilla and then until the di stasis to the proximal end of the duodenum, the back wall of the anastomosis is implanted duodenal small duodenal papilla then longitudinally cut through a front wall of the duodenum distal stump over corresponding recovery lumen and form an anterior-lateral wall anastomosis biased flaps mobilized distal end of the duodenum; upon destruction of the small and large duodenal papillae, the terminal sections of the Wirsung, Santorini and common bile ducts are distinguished from the cicatricial and ulcerative lesions, the edges of the posterior wall of the distal end of the duodenum are sewn along the circumferences of the Wirsung and common bile ducts, and then until the diastasis with the proximal end of the twelve is eliminated the back wall of the duodenal anastomosis is implanted with a santorinium duct, after which the front wall of the distal duodenal stump is longitudinally dissected into the length corresponding to the restoration of the lumen, and form the front-side walls of the anastomosis with displaced flaps of the mobilized distal end of the duodenum.

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