RU2363396C1 - Method of sealing ruptured peptic ulcers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: kollost membrane is used as a graft and is put on to a rupture. The size of the graft is larger than the rupture. The graft is fixed at the corners using interrupted suture. The edges of the graft are then sewn using continuous suture.

EFFECT: wider range of surgical measures for sealing ruptured peptic ulcers, preservation of the operated organ and its physiological clearance, complete sealing of the ruptured site, carrying out plastic repair in peritonitis conditions, after repeated operations without autografting material.

2 dwg, 1 ex

Description

The invention relates to medicine, in particular surgery, and can be used for suturing performative ulcers of the stomach and duodenum.

There are many known methods of suturing and plastic performative holes, which are based on the use of their own tissues (autoplasty). All of them mainly include an incision of the anterior abdominal wall, revision and excretion of an organ with a perforation site in the wound, the imposition of the first row of through knotted sutures to bring the edges of the ulcer defect closer and the subsequent subsequent second row of knotted sutures. Common disadvantages of these methods are deformation of the lumen of the hollow organ due to invagination of the walls and inevitable disturbances in blood supply, leading to the development of cicatricial ulcer stenosis of the pyloric-duodenal zone, which may require repeated surgery [1].

More than a hundred years later, when Mikulich first performed suturing performative ulcers. The improvement of suturing methods has not changed. Known methods for suturing perforations of hollow organs with additional reinforcement of the suture line with autoplastic material on the feeding leg: hemming the gland with additional gauze tamponade (Opel V.A., 1896); suturing with a mattress suture with plastic gland (Kontorovich MA); plastic reinforced gland on the leg (Savchik AB, 1958); fixation to the seam line of the omentum on the leg (Neymark II, 1958); hemming around the circumference of a lock of a large omentum on a feeding leg (Jordan R., Morrow C., 1988); plastic by serous-muscular flap of the stomach on the vascular pedicle (Kutukov V.E., 1989) [1, 2].

The above disadvantages of these methods include insufficient stimulation of regeneration and the possibility of relapse of the ulcer with the occurrence of complications (bleeding and peritonitis).

Other methods of suturing are used when it is impossible to double suturing using isolated local tissues as various additions in the form of autoplastic material: muscle tamponade followed by suturing according to V. A. Krasivtsev; plastic by sero-muscular flap of the stomach wall (Serebryannikov L.V. and Snezhkova V.P., 1940); plastic by an isolated omentum and parietal peritoneum (Kulichkov N.A., 1955) and other methods [1, 2, 3].

These methods include the use of the walls of their own and neighboring organs, the omentum, the round ligament of the liver, a piece of the wall of the gallbladder, which cover the holes, followed by suturing the edges.

However, an isolated omentum or other intrinsic tissue, deprived of nutrition, lengthens the healing time of the suturing site and does not contribute to the regeneration of the ulcer, which can lead to relapse of the ulcer and the need for repeated surgical intervention.

As a prototype, the method of suturing perforated openings of gastric and duodenal ulcers of the pyloroduodenal zone according to patent No. 2310401 (publ. November 20, 2007), including removing the perforated hole into the wound, applying a mesh allograft graft to the perforated hole larger than the size exceeding the size, was selected as a prototype ulcerative infiltrate, fixation of the allograft in the center of the flap to the adjacent edges of the perforated hole, fixation of the allograft with interrupted sutures in the corners, followed by flashing along the edges of the continuous nym suture, allograft overlay top strand omentum, which is fixed at the corners sutures [3].

This method has the following disadvantage - the mandatory use of a lock of a large omentum to prevent adhesions in the abdominal cavity and to achieve complete sealing of the perforation, because the mesh structure of the allograft does not allow to completely distinguish the liquid contents of the hollow organ (for example, the duodenum 12) from the abdominal cavity.

The objective of the invention is to expand the arsenal of methods for suturing perforated openings of gastric and duodenal ulcers of the pyloroduodenal zone, by creating a method that allows you to save the organ and its physiological clearance, to ensure complete sealing of the perforation even without the use of a large omentum, which will allow plastic conditions of peritonitis, as well as after repeated operations when there is no possibility of autoplasty (lack of omentum, gall bladder and other ganas ...).

The problem is solved due to the fact that in the proposed method, in contrast to the prototype, instead of an allograft flap, which is larger than the size of the perforated hole, a xenograft flap, for example, “Kollost” preparation, is used. The flap is cut out from a pre-made sterile collost plate, then it is fixed at the corners with separate interrupted sutures, after which the flap edges are stitched with a continuous suture, in the presence of a large omentum it is placed on top of the “Klost” flap and fixed with separate interrupted sutures.

Kollost is a sterile bioplastic collagen material. It is a lattice structure consisting of collagen fibers based on type I collagen, which has biologically active properties to heal a wound, activating its own fibroblasts. During the implantation of Kollost, the proliferation of fibroblasts producing fibers and the main substance of connective tissue increases, because various forms of Kollost are prepared from calf skin and treated so that the epidermis, subcutaneous fat layer and all dermal cells are removed without destroying the collagen matrix, creating an immunogenically inert and resistant material. The processing process allows you to save the matrix proteins and cytokines that are in the skin, while freeing from melanocytes, macrophages, lymphocytes, blood vessels and hair follicles. In the absence of these cells, the human immune system does not respond to this drug as a foreign body, without causing an inflammatory reaction or rejection effect. Therefore, this drug is already used by various specialists: in purulent surgery to close trophic ulcers and other skin defects, in traumatology to accelerate the regeneration of bone defects, in reconstructive surgery, in urology for sling operations for urinary incontinence. However, there is no known information on the possibility of using collagen for the treatment of ulcerative lesions of the mucous membranes of tissues.

A sign to confirm the conformity of the proposed technical solution with the criteria of “novelty” and “inventive step” is the use of the Kollost membrane for plasty of perforated ulcerative defects of the mucous membranes of the stomach and duodenum of the pyloric-duodenal zone in the abdominal cavity.

It was established for the first time that the use of the Kollost membrane in cases of peptic ulcer in the mucous membranes of the stomach and duodenum of the pyloric-duodenal zone not only restores the bottom of the ulcer, but also provides this zone with a matrix of a specific collagen protein, which, in turn, promotes scarring, but it does not stimulate the adhesion process, and the density of the protein structure allows hermetically delimiting the organ lumen from the abdominal cavity without the use of a large omentum lock.

An additional advantage is that the absence of invaginate during plastic surgery allows not only preserving the initial lumen of the organ, but also preventing the occurrence of peritonitis, preventing the ulcerative process during the elimination of a defect in the wall of the stomach or intestine, and preventing the development of stenosis in the postoperative period.

Using this method does not cause deformation of the pyloroduodenal zone, thereby preventing repeated surgical intervention.

The invention is characterized by the following drawings.

1. Figure 1 - defect, closed by a membrane “Kollost” and fixed by interrupted sutures in the corners.

2. Figure 2 - defect covered with a membrane and fixed with continuous seams.

The method is as follows. After removing the perforated hole into the wound, a flap of Kollost membrane is placed on it in size exceeding the perforated hole. The corners of the flap are fixed with separate interrupted sutures 1. Then, the edges of the flap are sutured with a continuous suture 2. After sanitation and drainage of the abdominal cavity, laparotomy wounds are sutured.

Example.

The method was used on 30 rats in the experimental group. After removing the ulcer into the wound, a “Collost” membrane flap is placed on it in size exceeding the perforated hole. The corners of the flap are fixed with separate interrupted sutures 2. Then the edges of the flap are sutured with a continuous suture 3. After rehabilitation and drainage of the abdominal cavity, the laparotomy wound is sutured.

A control group of 30 rats was operated using the double suturing technique.

The experimental results confirmed that in the experimental group, in contrast to the control group, narrowing of the organ lumen was not observed. Relapse of the ulcerative process and peritonitis and adhesions were not observed. The presence of the membrane at the bottom of the ulcer stimulated the proliferation of fibroblasts and their activity with the development of connective tissue and scarring of the ulcer (ulcer scarring occurred on the 30th day, as in the control group).

Thus, the use of this method will save the organ and its physiological clearance, reduce the risk of peritonitis and the continuation of the ulcer process, thereby preventing the development of stenosis in the postoperative period and will avoid repeated operations. The experimental data were histologically confirmed.

Literature

1. A.A.Shalimov, V.F.Saenko. "Digestive tract surgery." Kiev, 1987, p. 228-233

2. I.M.Matyash, A.M.Gluzman. "Directory of surgical operations." Kiev, 1979, p. 62-111.

3. N.A. Maistrenko, K.N. Movchan. "Surgical treatment of duodenal ulcers." St. Petersburg, 2000, p. 39-51.

4. Dementieva Anna Vladimirovna. The dissertation "Possibilities of using collagen (collost) as a material for sling operations for urinary incontinence in women", 11.01.2007.

5. Laurent O. B., Sinyakova L. A., Shishlo V. K., Dementieva A. V. Possibilities of using collagen (Kollost) as a material for sling operations for urinary incontinence in women (experimental study). // Obstetrics and gynecology, 2006, No. 2, p.30-33.

Claims (1)

A method of suturing perforated ulcers of the stomach and / or duodenum, including the use of a graft, characterized in that the membrane is used as a graft “Kollost”, while a graft flap is placed on the perforated hole, exceeding the size of the perforated hole, fix it at the corners with separate nodal sutures followed by stitching the edges of the graft with continuous sutures.

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