RU2351289C1 - Method of treatment of stump of duodenum at penetrating in pancreas head of ulcer with arrosion of pancreatic duct - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: duodenum is allocated and crossed. Cut with depth of 5-6 mm is carried out on the top contour of bottom of ulcer with formation of "canopy" from cicatrical tissue. Then stump of duodenum is taken in applying the noose sutures. Thus the first row of seams is imposed through all layers of forward wall of the duodenum with underrunning of the "canopy" from cicatrical tissue, partially invaginating forward wall of the duodenum in intestine lumen. The second row of noose sutures is imposed between serous-muscular cover of the anterior wall of the duodenum and thickened capsule of the pancreas above a line of the cut forming a "canopy" from a cicatrical tissue. Then peritonisation the seams imposed on the anterior wall of the duodenum and on the capsule of the pancreas is carried out.

EFFECT: method allows to lower invalidity of stump of duodenum at the expense of rising of reliability of its hermetic sealing, can be applied in planned and emergency surgery, is simple in workmanship.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of duodenal ulcers, penetrating into the head of the pancreas, complicated with arrosis of the pancreatic duct.

Isolation and intersection of the duodenum deformed by the cicatricial and ulcerative process, suturing of its stump is the most difficult step in performing a gastrectomy with an ulcer of the posterior medial wall of the duodenum, penetrating into the head of the pancreas, since the presence of cicatricial and ulcerative substrate and significantly reduces the possibility of a safe ulcer and reliable suturing of the duodenal stump. With the isolation and intersection of the duodenum at the level of the ulcer and the detection of pancreatic duct arrosion, it is impossible to close the duodenal stump with extraterritorialization of the penetrating ulcer from the lumen of the duodenum. Signs of the presence of pancreatic fistula in these cases is the accumulation of a clear fluid (pancreatic juice) at the bottom of the penetrating ulcer. In such cases, the stump is treated with an ulcer in the duodenum. The first row of sutures is applied between the anterior wall of the duodenum and the upper edge of the ulcer. The second row of sutures is stapling of the anterior wall of the duodenum with a capsule of the pancreas. Additional peritonization by a strand of a large omentum along the line of sutures. When the first row of sutures is applied beyond the edge of the ulcerous ulcer, eruption of suture threads is possible, since the edge of the ulcer is loose. In such cases, the likelihood of developing failure of the sutures of the stump of the duodenum with the development of peritonitis and duodenal fistula increases. Mortality in this case reaches 50% and higher.

A known method of closing the stump of the duodenum during gastric resection due to penetrating into the pancreas ulcers with arthrosis of the pancreatic duct, including plastic sheathing of the suture line by a serous-muscular autograft from the stomach wall on the vascular pedicle (patent RU No. 2016548, IPC А61В 17/00). The known method is quite complicated in technical design, autograft necrosis is possible, the problem of the reliability of the superimposed rows of stitches of the duodenal stump is not resolved

The objective of the invention is to reduce the incidence of insolvency of the stump of the duodenum and, as a consequence, to reduce postoperative mortality.

The technical result is to increase the reliability of sealing the stump of the duodenum

The problem is solved by a method of treating a duodenal stump with an ulcer penetrating into the head of the pancreas with pancreatic duct arthrosis, including the isolation and intersection of the duodenum, making an incision 5-6 mm deep along the upper contour of the ulcer bottom with the formation of a “visor” from the scar tissue and stump by applying nodal sutures, in which the first row of sutures is applied through all layers of the anterior wall of the duodenum with piercing of the “visor” from scar tissue, often By invaginating the anterior wall of the duodenum into the lumen of the intestine, a second row of nodal sutures is applied between the serous-muscular membrane of the anterior wall of the duodenum and the thickened capsule of the pancreas above the incision line, forming a “visor” from the scar tissue, and then peritonization of the anterior sutures is applied the wall of the duodenum and per capsule of the pancreas.

Figure 1 shows a frontal section of an unhealed duodenal stump and surrounding tissues, conducted through an ulcer and head of the pancreas; figure 2 is a frontal section of the sutured duodenal stump in the final version.

In the implementation of the proposed method, the treatment of the stump of the duodenum with ulcers penetrating into the head of the pancreas is as follows. They mobilize the stomach within the resection. The duodenum intersects at the level of the distal edge of the ulcer penetrating into the head of the pancreas. If pancreatic duct 1 arrosis is detected, a bordering incision 2 is performed at a distance of 5-6 mm along the upper contour of the ulcer floor, with a depth of 5-6 mm. At the same time, scar-sclerotic pancreatic tissue is dissected. A rather strong “visor” is formed from scar tissue, for which the first row of nodal sutures 3 is applied, partially invaginating the front wall of the duodenum into the lumen of the intestine. Already this is achieved quite reliable sealing of the stump of the duodenum. The second row of nodal sutures 4 is imposed for the serous-muscular membrane of the anterior wall of the duodenum and the thickened capsule of the pancreas above the incision line forming the “visor”. Additional peritonization is carried out by sutures 5 superimposed on the front wall of the duodenum and behind the capsule of the pancreas. The operation ends with the removal of the distal part of the stomach within the resection and the formation of a gastroenteroanastomosis, usually a transverse valvular, vertically oriented, which creates better conditions for the promotion of duodenal contents.

Example

Patient K., 56 years old, was in the surgical department with a diagnosis of Duodenal ulcer, complicated by penetration into the pancreas and subcompensated stenosis. He was admitted with complaints of pain in the epigastric region, nausea and periodic vomiting. When fibrogastroduodenography revealed the presence of ulcers in the postbulbar part of the duodenum - on the front wall of 5-6 mm and on the back wall of 2.5-3.0 cm with an inflammatory shaft around, as well as the presence of stenosis of 0.9 mm in diameter. After preoperative preparation, an operation was performed - resection of 3/4 of the stomach according to Vitebsk. From the protocol of operation: a large stomach, a large number of adhesions in the area of the duodenum. After dissection of adhesions, ulcers of the postbulbar part of the anterior wall and posterior wall of the duodenum were revealed. Mobilization of the duodenum with great technical difficulties, processing the post-bulbar part of the duodenal stump in an open way with crossing it along the upper contour of the bottom of the ulcer, penetrating into the head of the pancreas. Due to the presence of a transparent secretion at the bottom of the penetrating ulcer, the pancreatic duct arrosion is suspected, after which the stump is processed according to the proposed method - three-row nodal sutures along the upper contour of the ulcer bottom are applied. Resection 3/4 of the stomach within the resection. The upper half of the stomach stump is sutured with a two-row interrupted suture, and the lower half is anastomosed with a short loop of the small intestine according to Vitebsk. The postoperative period is smooth. The patient was discharged after two weeks in satisfactory condition.

The inventive method of suturing the stump with duodenal ulcers, penetrating into the pancreas with pancreatic duct arrosis, is technically simple to perform, reliable. It can be used in planned and emergency surgery.

Claims (1)

A method of treating a duodenal stump with an ulcer penetrating into the head of the pancreas with pancreatic duct arrosis, characterized by the isolation and intersection of the duodenum, making an incision 5-6 mm deep along the upper contour of the ulcer bottom with the formation of a “visor” from scar tissue and subsequent scarring sutures, in which the first row of sutures is applied through all layers of the anterior wall of the duodenum with piercing of the “visor” from the scar tissue, partially invaginating the middle wall of the duodenum into the lumen of the intestine, the second row of nodal sutures is applied between the sero-muscular membrane of the anterior wall of the duodenum and the thickened capsule of the pancreas above the cut line, forming a “visor” of scar tissue, and then peritonization is performed with sutures placed on the anterior wall intestines and per capsule of the pancreas.

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