RU2334473C1 - Method of surgical treatment of inefficiency of sutures of duodenum stump - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: after removal from stump all previously made sutures, its non-viable edges are dissected. Anterior wall and mucous-submucous layer of posterior gut wall are mobilised. Suture is made in longitudinal, relative to pancreas axis, direction, from the middle of posterior semi-circle of stump to the middle of anterior semi-circle. First, edges of mobilised mucous-submucous layer of posterior wall are sutured. Then suture passes through all layers of anterior wall of stump released from adhesion. Further on, two semi purse-string sutures are made, first needle stick in both semi-purse-string sutures being made into demucosed muscle layer of posterior wall. Semi-purse-string sutures are tied with submerging and pulling sutured stump to pancreas head.

EFFECT: method prevents inefficiency of sutures, peritonitis and formation of external duodenal fistula.

Description

The invention relates to medicine, in particular to the field of surgery, and can be used for the treatment of patients with failure of sutures of the stump of the duodenum after resection of the stomach.

A known method for the treatment of insolvency of sutures of the stump of the duodenum, namely, that the defect in the suture line is sutured with interrupted sutures, a drainage tube and a tampon are brought to the stump (Shalimov A.A. Surgery of the stomach and duodenum / A.A. Shalimov, V.F. .Saenko. - Kiev: Health, 1972. - 356 p.).

The disadvantage of this method is the possibility of developing repeated failure of the sutures with the progression of peritonitis or the formation of an external duodenal fistula.

The purpose of the invention is to improve the results of surgical treatment of patients with inconsistency of sutures of the stump of the duodenum, which developed after resection of the stomach.

The goal is achieved by the fact that after removal of all previously applied sutures from the duodenal stump and excision of non-viable tissues, the duodenum is mobilized, the stump is covered with a two-row suture with elements of precision technique, and the causes of intraduodenal hypertension are eliminated.

The method is implemented as follows. Under endotracheal anesthesia, median relaparotomy is performed. Exudate is evacuated using an electric suction pump. An audit of the abdominal organs is performed. After the failure of the sutures of the stump of the duodenum is detected and the area is delimited by tampons from the duodenal stump, all previously applied sutures are removed. An audit of the large duodenal papilla is performed, the depth of its location is specified. Necrotic edges of the intestine are excised within viable tissues, while the greatest difficulties for subsequent shelter are the shortening of the posterior wall of the duodenal stump, since its additional secretion is associated with a risk of damage to the pancreas and elements of the hepatoduodenal ligament.

The upper horizontal part and the upper bend of the duodenum are mobilized according to Kocher. The front wall of the duodenum is carefully freed from multilayer planar adhesions and scarred tissues to give it the greatest mobility. The mucous-submucous layer of the posterior wall of the duodenum is separated from the muscle layer for 1 cm.

When stitching the duodenal stump, elements of precision technique are used. The lumen of the intestine is hermetically closed with a continuous suture of absorbable material 4/0 on an atraumatic needle (first row). The suture is applied in the longitudinal direction with respect to the axis of the pancreas from the middle of the posterior semicircle of the duodenal stump to the middle of the anterior semicircle. First, the edges of the mobilized mucous-submucosal layer of the posterior wall are sutured, then the suture passes through all layers of the anterior stump isolated from the adhesions. After this, two half-mesh seams of non-absorbable material (second row) are applied on both sides of the continuous seam, and the first needle injection of both half-mesh seams is made into the demucous muscle layer of the posterior wall. As a result, when tying half-netted sutures, the sutured duodenal stump is immersed and pulled to the head of the pancreas.

The causes contributing to an increase in intraduodenal pressure are eliminated: the Treitz ligament is dissected and the duodenojejunal bend is reduced, the spur of the adducting loop is “strengthened”, excesses and adhesions in the area of the discharge loop of the jejunum are eliminated. Sanitation and drainage of the abdominal cavity is performed, one of the drainage tubes is brought to the duodenal stump. The laparotomic wound is sutured in layers.

When using the prototype method, the possibility of repeated failure of the sutures with the development of peritonitis or the formation of an external duodenal fistula was due to the fact that the sutures were superimposed on non-viable tissue of the duodenum; the tension of the sutures led to a violation of the blood supply to the intestinal wall; the causes of intraduodenal hypertension persisted. When using our version of the operation, non-viable tissue is excised; the tension of the joints is eliminated by mobilization of the anterior wall and the mucous-submucosal layer of the posterior wall of the stump; causes of increased pressure in the duodenum are eliminated. In addition, the use of elements of precision technology when suturing the first row increases its reliability, and the seams of the second row do not pass through the capsule and pancreatic tissue, which is an effective measure for the prevention of postoperative pancreatitis.

According to the literature, the incidence of failure of sutures of the stump of the duodenum after resection of the stomach ranges from 0.1 to 9% and averages 3% (Chernousov A.F. Surgery of peptic ulcer of the stomach and duodenum: Hand. For doctors / A.F. Chernousov, P.M. Bogopolsky, F.S. Kurbanov. - M .: Medicine, 1996. - 256 p.). With the development of peritonitis due to the failure of the sutures of the duodenal stump, the probability of a favorable outcome does not exceed 30% (Peritonitis: Pract. Hands / Under the editorship of BC Saveliev, B.R. Gelfand, M.I. Filimonova. - M .: Litterra, 2006. - 208 p.). Authors using stitching stump defect report a low efficiency of this method. So, G.A. Ivashkevich et al. (1973) undertook suturing of the duodenal stump with the failure of its sutures in 2 patients. In both cases, the sutures again parted for 3-4 days, which led to the death of 1 patient from diffuse peritonitis (Ivashkevich G.A. Tactics of a surgeon with divergence of sutures of the duodenal stump after resection of the stomach / G.A. Ivashkevich, L.R. , E.A. Yurmin // Surgery. - 1973. - No. 1. - P.23-26.). I.A. Petukhov (1980) applied stitches to a stump defect in 5 patients, 2 of whom died (I. Petukhov Postoperative peritonitis / I.A. Petukhov. - Mn .: Belarus, 1980. - 158 p.) . A.Z. Magomedov and A.D.Dibirov (1980) stitched a defect in a duodenal stump in 3 patients, while 2 of them died (A.Z. Magomedov. Insufficiency of a duodenal stump after gastrectomy with gastroduodenal ulcers / A.Z. .Magomedov, A.D. Dibirov // Surgery. - 1980. - No. 7. - S.62-65). However, the frequency of repeated failure of the sutures imposed on the defect of the duodenal stump, these authors do not report. The accumulation of material in subsequent years allowed O. B. Milonov et al. (1990) to conclude that “collective experience is not in favor of re-suturing an inconsistent stump” (O. Milonov, Postoperative complications and dangers in abdominal surgery / O. B. Milonov, K. D. Toskin, V. V. Zhebrovsky. - M .: Medicine, 1990. - 560 p.). A generalizing conclusion was made by N.N. Kanshin (2004): “It should be recognized as almost an axiom that the imposition of additional sutures on the failed duodenal stump is almost unpromising” (NN Kanshin Surgical treatment of postoperative peritonitis caused by intestinal suture failure / N.N. Kanshin. - M.: Profile, 2004 .-- 64 p.).

We applied the developed method for surgical treatment of suture failure of the duodenal stump in 12 patients. In one case, repeated suture failure of the duodenal stump occurred due to a technical error during the development of the technique. 4 patients died, 1 of them - from the progression of peritonitis and 3 - from other causes (pneumonia, acute cardiovascular failure, pulmonary thromboembolism). The remaining 8 patients recovered and were discharged from the hospital 9-14 days after the application of the developed method.

Claims (1)

A method of surgical treatment of inconsistency of sutures of the duodenal stump by suturing the duodenum, characterized in that all previously applied sutures are removed from the duodenal stump, non-viable tissues are excised, the anterior wall is mobilized and the mucous-submucosal layer of the posterior intestine is sutured in relation to to the axis of the pancreas, direction from the middle of the posterior semicircle of the stump to the middle of the anterior semicircle, the edges of the mobilized mucosa-submucosa are first sutured a single layer of the posterior wall, then the seam passes through all layers of the anterior wall of the stump extracted from the adhesions, after which two half-mesh sutures are applied, the first needle injection of both half-mesh sutures is made into the demucous muscle layer of the posterior wall, the half-mesh sutures are tied with immersion and pulling of the sutured stump to the head of the pancreas.