RU2375970C2 - Method of surgical treatment of external duodenal fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, surgery. After dissection and sewing of externall duodenal fistula, shutting off of duodenum is carried out. Treitz ligament is transected. Indenting 40 cm from Treitz ligament, first part of small intestine is taken and transected. Proximal part of intestine is freed from mesentery, preserving blood supply of its wall on 3 cm. Two lateral traction sutures are applied. Indenting 3-4 cm from borders of mesentery-free part of small intestine, longitudinal 2 cm long cut of small intestine wall is performed on counter-mesentery surface. Two traction sutures are applied on wound edges. Walls of formed wound are moved apart by means of earlier applied two traction sutures. Through enterotomy wound by means of forceps traction sutures of mesentery-free part are gripped and its invagination into intestine lumen to distal edge of enterotomy wound is carried out. By means of interrupted suture through all layers of intestine wall counter-mesentery surface of invaginated part is sewn with distal edge of enterotomy wound. Areflux valve is formed due to fitting of loosely hanging into intestine lumen counter-mesentery edge. Proximal part is brought out 10 cm lower than edge of left rib arch on anterior axillary line through separate cut. Distal part of small intestine is used for formation of Roux gastroenteroanastomosis. After that inter-intestinal entero-enteroanastomosis is applied between first part of small intestine, indenting 15 cm from transected Treitz ligament, and small intestine loop, used for gastroenteroanastomosis, 20 cm lower than latter. Into duodenum through jejunostome to stump cupula passed is chlorovinyl tube with diametre 0.5 cm with lateral perforation holes with diametre 0.3 cm, located on its distal part in duodenum lumen for carrying out duodenal decompression.

EFFECT: method ensures full-fledged decompression of duodenum, early enteral feeding in post-operation period; reduces risk of duodenal fistula recurrence and various purulent complications, does not require special equipment and tools; is simple in operative implementation.

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Description

The invention relates to medicine, namely to surgery.

Surgical treatment of fistula of the digestive tract is the most difficult section of purulent surgery. The danger of this pathology is associated with a progressive loss of digestive juices, which contain a variety of proteins and electrolytes, the loss of which leads to progressive intoxication, serious disturbances in homeostasis and a change in digestion processes, and, consequently, to a progressive deterioration of the patient's body as a whole and a decrease in its compensatory capabilities.

Particularly difficult situations are associated with the development of duodenal fistula, characterized by abundant loss of bile, pancreatic and gastric juices. With duodenal fistula, due to the physiological characteristics of the duodenum, the patient is in a serious condition and extremely high mortality rates, reaching 98%. Over the past decade, there has been an increase in duodenal fistula, which is caused by a trauma of the duodenum and a large number of distal resections of the stomach due to its various diseases, such as cancer and gastric ulcer. The presence of a duodenal fistula causes purulent complications, such as a paraduodenal abscess, peritonitis, and retroperitoneal phlegmon, which determine the surgeon’s desire for reconstructive surgery on the formed duodenal fistula to avoid the occurrence of such formidable complications mentioned above.

The prototype of the method, the authors offer a circular resection of the intestine along with the fistulous course according to the Billroth method. Around the fistulous opening, departing from the edges of the intestinal mucosa 2-3 cm, preferably within healthy skin, produce two bordering incisions to the aponeurosis. The edges of the skin flaps formed are sewn over the fistula with silk ligatures, which ensures aseptic treatment for the subsequent stages of the surgical intervention. The aponeurosis, muscles and peritoneum are gradually excised, pulling the silk sutures into the wound, the block leads to the fistula area, which leads and leads loops, and splits are separated. Especially carefully should examine the outlet section of the intestine, straighten it and eliminate excesses. Fence swabs are inserted into the abdominal cavity and a conventional small bowel resection is performed along with a fistula. Anastomosis form “end to end” or “side to side”, the wound of the abdominal wall is closed tightly layer by layer (Bogdanov A.V. - Digestive tract fistulas in the practice of a general surgeon - Moscow - 2001 - p. 111).

The disadvantages of the method are:

1. The method is traumatic;

2. Promotes the additional formation of duodenal fistula;

3. Requires a great technical skill in applying a duodenal anastomosis;

4. Able to form retroperitoneal phlegmon.

The authors suggest their own method of surgical treatment of the external duodenal fistula (see drawing). Verkhnesomedinaya laparotomy is performed. Then, retreating 0.5 cm from the edges of the external fistulous opening, a bordering incision of the skin and then the underlying tissues is made until aponeurosis. After that, the surgical field is delimited by sterile napkins and the fistulous passage is stained with methylene blue, then the tissues surrounding the fistulous passage are cut to the internal opening of the duodenal fistula. Then they begin to mobilize the duodenum according to Kocher. At the border of the pylorus and the upper horizontal section of the duodenum, flashing with the UO-60 device is performed. Then, between the mechanical joints, tissue is dissected. This achieves the stage of "turning off the duodenum." Then, with the help of a purse string suture, the mechanical suture is immersed in the duodenum. After this, a gray-serous Z-shaped suture is imposed, thereby preventing the failure of the duodenal stump. The mechanical suture of the stomach is immersed by applying individual nodal sutures. Having diagnosed the internal fistulous opening and 0.5 cm departing from it, the duodenal fistula is excised together with the wall of the duodenum. The fistulous course preparation with a skin flap and duodenal tissues is removed. Then the edges of the duodenal wound are treated with an alcohol solution of chlorhexidine, after which separate nodal sutures are applied transversely to the duodenal wound. 1 cm away from the first (lateral) nodal suture, a second row of nodular gray-serous duodenal sutures is applied in the longitudinal direction, i.e. perpendicular to the first duodenal suture. The distance between the seams of the second row is 0.5 cm, and its length is equal to the length of the first row of seams. Further, departing from the second longitudinal suture lateral than 0.5 cm, the third gray-serous row of sutures is applied 1.5 cm longer than the previous one. This ensures the wrapping of the wall of the duodenum, and hence the strengthening of its hermeticity. Then cross the ligament of the Traits. Next, take the initial section of the jejunum, retreating 40 cm from the ligament of the Traits, and cross it. The proximal section of this segment is freed from the mesentery without disturbing the blood supply to its wall for 3 cm. Next, two lateral suture-holders are placed on it. After that, retreating 3-4 cm from the borders of the mesenteric section of this segment of the jejunum, a longitudinal section of the jejunum wall is made on the 2-cm length mesenteric surface. Two suture-holders are applied to the edges of the wound wall. After that, the walls of the resulting wound are bred with the help of two superimposed suture-holders. Then, through the enterotomic wound, with the help of a clamp, the sutures-holders of the segment freed from the mesentery are captured and it is invaginated into the intestinal lumen to the distal edge of the enterotomic wound. Then, using nodal sutures through all layers of the intestinal wall, the mesenteric surface of the invaginated segment is sutured to the distal edge of the enterotomy wound. Thus, the areflux valve is formed, due to the fit of the mesenteric edge freely hanging in the intestinal lumen. This proximal section is displayed 10 cm below the edge of the left costal arch along the anterior axillary line through a separate incision. The distal jejunum 50 cm long is mobilized. Next, an intestinal entero-enteroanastomosis is applied between the initial section of the jejunum, departing 15 cm from the dissected Ligament of Traits and the loop of the jejunum used for gastroenteroanastomosis, 20 cm below the last. cm with lateral perforations of 0.3 cm for duodenal decompression. The operation is completed by drainage of the subhepatic space by tubular drainage. Surgical wounds are sutured in layers.

The method of surgical treatment of the external duodenal fistula proposed by the authors has several advantages:

1. Promotes the prevention of purulent-septic complications in the abdominal cavity and in the retroperitoneal space;

2. The specified method is less traumatic;

3. Provides reliable sealing;

4. Easy to execute;

5. Reduces the patient’s hospital stay.

The authors operated on 4 people according to the method described above. Clinical example: case history No. 431, patient A.V., aged 37, was admitted to the surgical department with a duodenal post-traumatic fistula. The patient was operated on as described above. The postoperative course is smooth. On the 17th day, the patient in satisfactory condition was discharged home.

Claims (1)

The method of reconstructive surgery after excision of the external duodenal fistula, including flashing and turning off the duodenum, characterized in that after suturing and excision of the external duodenal fistula, the Trican ligament is intersected, 40 cm retreating from the Trican ligament, the intestine is taken and then her, the proximal section is freed from the mesentery, while maintaining blood supply to its wall for 3 cm, 2 lateral sutures are placed on it, after it, departing 3-4 cm from the borders of the mesenteric section of the jejunum segment, make a longitudinal incision of the jejunum wall on the 2 cm length mesenteric surface, two suture-holders are applied to the edges of the wound wall, after that the walls of the resulting wound are bred using two previously applied suture-holders, through the enterotomic wound with the help of a clamp, capture the suture-holders of the segment freed from the mesentery and carry out its invagination into the lumen of the intestine to the distal edge of the enterotomic wound, using nodal sutures of the cranium all layers of the intestinal wall, the mesenteric surface of the invaginated segment, are sutured to the distal edge of the enterotomy wound and the areflux valve is formed due to the adherence of the mesenteric edge freely hanging in the intestinal lumen, the proximal section is brought out 10 cm below the edge of the left costal arch along the front axillary line through a separate section, the distal section of the jejunum is used to form a gastroenteroanastomosis according to Ru, then an intestinal entero-enteroanastomosis is applied between the initial section of the jejunum, sludge 15 cm from the dissected ligament of Treits, and a loop of the jejunum used for gastroenteroanastomosis, 20 cm below the last, into the duodenum to the dome of the stump through the junction, a vinyl chloride tube with a diameter of 0.5 cm with lateral perforations located on its distal segment in lumen of the duodenum with a diameter of 0.3 cm for the implementation of duodenal decompression.

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