RU2316263C1 - Method for radical duodenoplasty in case of complicated chronic duodenal ulcer at focal localization being along greater bulbar curvature and transition onto its posterior wall - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: it is necessary to radically dissect the part of duodenal wall within the limits of cicatricial-ulcerous lesion; perform duodenoplasty; moreover, ulcerous crater on pancreas or hepatoduodenal ligament should be omentized with the strand of lesser omentum upon vascular pedicle to protect the line of duodenal anastomosis and liquidating the focus of ulcerous penetration. The part of lesser omentum should be matched under the control of transillumination under condition of keeping the circulation in it. The innovation enables to exclude complicated induced by traumatization of pancreas, gastroduodenal artery, keep the integrity of intraduodenal vascular and nervous duodenal bonds, reliably liquidate the focus of ulcerous penetration, prevent the development of post-surgical pancreatitis, decrease the duration and traumatism of operation.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to surgical gastroenterology, and can be used in surgery of complicated duodenal ulcers (duodenal ulcer).

According to domestic authors, duodenal ulcer is detected in approximately 12-18% of the adult population (Komarov F.I., 1995).

Surgical interventions for penetrating duodenal ulcers constitute one of the most difficult sections of abdominal surgery, due to the anatomical complexity of this zone.

Numerous so-called organ-preserving technologies, in the scope of vagotomy and drainage operations for duodenal ulcers, are performed either without intervention on the ulcer itself, or with the bleeding ulcer being stitched and the ulcer crash tamponed with the wall of the stomach or duodenum, which can cause complications such as failure of sutures and periton , pancreatitis, pancreatic necrosis.

As an analogue, a method is known for treating duodenal ulcer by performing radical duodenoplasty with access to the posterior wall of the bulb from the omentum through the pyloropancreatic ligament (V.I. Onopriev et al. Method for radical duodenoplasty in case of duodenal ulcer complicated by pancreatic penetration localization of the focus within the posterior wall of the bulb body (Patent No. 2218874, 2003).

The method involves excising the edges of the ulcer and scar tissue of the duodenal bulb while maintaining the continuity of the anterior and lateral walls, and access to the posterior wall is provided from the greater omentum through the pyloropancreatic ligament, separation of the duodenopancreatic infiltrate, the suture line is straightened by the large omentum with the posterior duct and the anastomus is formed guts.

The disadvantage of this method is: the possibility of trauma to the pancreas, gastroduodenal artery during the stage of tunneling of the retrobulbar space from the omentum, with access to the scar-ulcerative focus of the posterior semicircle of the bulb, the need to mobilize the strands of the omentum on the vascular pedicle for omentoplasty.

As the closest analogue, a method for treating duodenal ulcer by excising an ulcer followed by stitching of the edges of the defect (V.I. Onopriev, Yu.G. Zamulin. Method for treating duodenal ulcer. Patent No. 971286, 1993) is adopted. The method involves transverse dissection of the anterior wall of the duodenum, mobilization of the posterior wall, excision of pathologically altered tissues, release of the suprabulbar and pyloric portions along the posterior wall, straightening the pseudo diverticulum wall from the mucosa, restoration of the duodenal ampoule, followed by suturing of the excised edges of the defect.

The disadvantage of this method is the interruption of intraduodenal vascular and nerve connections with subsequent violation of the motor-evacuation functions of the duodenum, as well as the intersection of the anterior wall, not damaged by the scar-ulcer process, the need to mobilize the right half of the greater omentum on the vascular pedicle for omentoplasty.

Tasks: increasing the effectiveness of surgical treatment of complicated chronic duodenal ulcers, reducing mortality and postoperative complications, reducing treatment time, improving the quality of life and reducing the period of disability and disability.

The essence of the invention lies in the fact that the ulcer crater on the pancreas or hepatoduodenal ligament to protect the duodenal anastomosis line and eliminate the ulcerative penetration focus is identified by a strand of small omentum on the "vascular pedicle", and the site is selected under the control of transillumination with the condition of maintaining blood supply in it.

The technical result of the proposed method consists in the fact that by performing radical duodenoplasty with an complicated ulcer of a large curvature of the bulb with a transition to its posterior wall by the claimed method, it is possible not only to radically eliminate the complicated ulcer of the duodenum, but also to perform an ulceration of the ulcer crater on the pancreas with an omentum on the "vascular pedicle", thereby protecting the line of the duodenal anastomosis, reducing the possibility of trauma to the pancreas of the gastroduodenal artery, the continuity of the intraduodenal vascular and nerve connections of the duodenum is preserved, the focus of ulcerative penetration is reliably eliminated, which can significantly improve the functional results of surgical interventions for complicated duodenal ulcers, prevent the failure of anastomotic sutures, develop postoperative pancreatitis, and reduce the duration and incidence of surgery lack of need for mobilization from the transverse colon and the allocation of a lock of the greater omentum on the vascular pedicle.

The execution of the method is additionally illustrated in the drawings, where (Figure 1): 1 - gastroduodenal junction, 2 - cicatricial-ulcerative deformation of the duodenum; (Figure 2): 3 - the lower contour of the post ulcerated scar of the anterior wall of the duodenum, 4 - the pylorus, 5 - the large duodenal papilla; (Figure 3): 6 - serous-submucosal suture-holders, 7 - single-row nodular external serous-muscular-submucosal suture with monofilament, involving the tissue of the small omentum. (Figure 4): 8 is a line of a single-row seam.

The method is as follows.

After performing the upper middle laparotomy, an external intraoperative study of the gastroduodenal 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. Before mobilization of the duodenum after separation of the cicatricial fusion with surrounding organs, mobilization of the duodenum and removal of the scar-inflammatory mantle from the serous membrane, the nature of the scar-ulcerative deformity of the duodenum and the localization of the scar-ulcerous lesion of clause 2 are determined. The structural safety of the anterior wall, minor curvature, and bulbous vessels is determined. In order not to damage the pylorus, transverse duodenotomy is performed along the lower edge of the scar-ulcerative focus of claim 3. Next, an intraduodenal (instrumental and palpation) study of the scar-ulcerative lesion is carried out, followed by a portioned expansion of the duodenotomy. Localization of an ulcer (scar) is determined by the large curvature of the bulb, the level of damage (basal, corporal, apical, post-bulbar). Identify the safety of the remaining walls of the bulb and bulb vessels. The ratio of the scar-ulcerative lesion to the pylorus, the large duodenal papilla of item 4, 5 is determined.

Under visual and palpation control, the edges of the ulcer and the scar-transformed periulcerous zone are radically excised. In the area of penetration, ulcers along large curvature stupidly divide the duodenum and pancreas. An ulcerative crater is cleaned of a layer of necrosis with a Volkman spoon, treated with alcohol, and if necessary, hemostasis is performed.

To perform the omening of a ulcerative crater with a penetrating duodenal ulcer, a lock of a large omentum is most often used (Patent No. 2218874, 2003). This is due to the need to mobilize the greater omentum from the transverse colon over a large extent, to additionally cut out the strands of the omentum on the vascular pedicle, which is subsequently used to identify the ulcerative crater and duodenal anastomosis line. If the pyloric ulcer is localized due to large curvature or large curvature with transition to the posterior wall of the duodenum, it is “inconvenient” to use a large omentum, since a certain tension is created when an omentum is placed, with possible violation of blood supply in it. Applicants suggest using tissue of the lesser omentum, which is anatomically closer to the affected area, but in the lesser omentum there are blood vessels and branches of the vagus nerve that supply and innervate the antrum, pylorus and bulb of the duodenum. In this regard, the choice of a site for omenization should be careful, taking into account the specified features. All manipulations are carried out under the control of vision and palpation. The study of angioarchitectonics and innervation of the omentum is advisable to carry out using transillumination.

On the edges of the duodenal wound impose serous-submucosal sutures-holders p.6. A single-row nodular external serous-muscular-submucosal suture with monofilament 4-5 / 0 is used, with the involvement of the tissue of the lesser omentum, clause 7, into the suture line. From above, the line of a single-row seam of item 8 is additionally peritonized with an omentum.

The proposed method operated on 16 patients with a duodenal ulcer complicated by penetration into the pancreas and localized along a large curvature with a transition to the posterior wall of the pyloric duodenum. In 2 patients, penetration was accompanied by arrosive bleeding. The postoperative period in all patients proceeded without complications, the wound healed by primary intention. On the 7-10th day, all patients were discharged for sanatorium or outpatient rehabilitation when examining the patients a month after radical duodenoplasty, no patients recurred ulcers, and the motor-evacuation function of the duodenum was not impaired.

EXAMPLE.

Patient Ch., 36 years. Peptic history of 5 years. Hospitalized in a clinic with a duodenal ulcer, accompanied by severe pain. On FGDS - peri-pyloric ulcer of large curvature with the transition to the posterior wall, 0.8-0.6-0.2 cm in size, complicated by subcompensated basal-corporal stenosis. The patient was offered surgery in the amount of radical duodenoplasty.

An intraoperative study in the gastroduodenal junction revealed stenotic basal deformity. The cicatricial and ulcerative lesion is localized along the great curvature of the bulb with the transition to the posterior wall. Cicatricial cords securing the duodenum to the hepatoduodenal ligament, liver, and pylorus extend from the cicatricial retraction zone from the side of the serous membrane.

Under the duodenum and around the head of the pancreas, 200 ml of a 0.25% solution of novocaine was introduced. The duodenum, together with the head of the pancreas, is mobilized with the dissection of the paraduodenal parietal peritoneum along the upper and descending parts. Cicatricial cords are separated, cicatricial inflammatory mantle is removed from the serous membrane.

Cicatricial-ulcerative infiltrate is localized along a large curvature with a transition to the posterior wall. The front wall, slight curvature are not involved in the cicatricial inflammatory process, the blood supply to these walls of the duodenum is not impaired. Transverse duodenotomy is performed along the lower edge of the scar-ulcerative focus.

An intraduodenal (instrumental and palpation) study revealed that the pylorus and the large duodenal papilla are intact. An ulcer 12 × 10 × 6 mm in size is localized along a large curvature with a transition to the posterior wall of the basal-corporal section of the bulb. A thrombosed vessel is detected in the ulcer crater, the ulcer penetrates into the pancreas and hepatoduodenal ligament. Under visual and palpation control, the edges of the ulcer and the scar-transformed periulcerous zone are radically dissected, preserving the bridge along the lesser curvature and posterior wall. The ulcerative crater was cleaned of a layer of necrosis using a Volkman spoon, treated with alcohol, and ligation of short pancreato-duodenal vessels was performed.

Before applying a duodenal anastomosis, in order to perform an omening of a ulcerative crater, a lock of a small omentum was cut out on a “vascular pedicle” using transillumination (to control angioarchitectonics and innervation of a small omentum).

After omenization of the ulcerative crater, single-row nodular serous-muscular-submucosal sutures were applied with PDS 4 / 0-5 / 0 monofilament, with a small omentum flap being taken into the suture line. The “bridge” along the lesser curvature and the back wall is preserved. From the side of the serous membrane, the suture line is additionally covered by a lock of a large omentum.

The postoperative period was uneventful, the patient was discharged from the hospital on the 7th day after the operation. During the follow-up examination 1 month after the operation, the motor-evacuation function of the duodenum was not impaired, on FGDS - no data were obtained for relapse of the ulcer, there were no signs of inflammation in the anastomotic zone. After 3 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 duodenal ulcers, to prevent the development of inconsistency of the sutures of the duodenal wound, postoperative pancreatitis, to reduce the duration and invasiveness of the operation.

The method is recommended for practical use.

Medical and social effectiveness. The proposed method for the surgical treatment of complicated duodenal ulcers with localization of the lesion along the greater curvature of the bulb and transition to the posterior wall can significantly improve the results of surgical treatment of chronic duodenal ulcer and is characterized by a complete cure for peptic ulcer, the absence of 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)

Method of radical duodenoplasty in case of complicated chronic duodenal ulcer with localization of the lesion along the greater curvature of the bulb and transition to its posterior wall, including radical excision of the duodenal wall within its scar-ulcer lesion, followed by duodenoplasty, characterized in that the ulcer or ulcer hepatoduodenal ligament to protect the line of duodenal anastomosis and eliminate the focus of ulcerative penetration omentiziruyut a lock of a small omentum on "vascular ’leg”, and the site is selected under the control of transillumination with the condition of maintaining blood supply in it.

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