RU2404716C2 - Method for duodenal bypass in case of wilkie's disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical treatment of Wilkie's disease, in particular to duodenal bypass from food passage and its drainage. For this purpose stomach is mobilised along greater and lesser curvatures. Resection is carried out along indicated resection line and below pyloric sphincter. Peritonisation of gastric remnant and duodenum is carried out. Afterwards anastomosis is formed between gastric remnant along greater curvature and shortest loop of small intestine laid in isoperistaltic direction, by means of electric coagulation without opening of lumens of anastomosed organs. Initial loop of jejunum is transected to form transplant with proper blood circulation. Caudal end of bypassed intestine is peritonised. Anastomosis is formed between oral end of transected intestine and distal part of jejunum. Duodenojejunoanastomosis is created between lower horizontal part of duodenum and intestine transplant isolated from digestion.

EFFECT: method makes it possible to drain duodenum, to reduce contamination of operative field, anastomositis, to accelerate epithelisaton of anastomosis, to prevent reflux-gastritis of gastric remnant and afferent loop syndrome.

4 dwg

Description

The invention relates to medicine, namely to one of its sections - surgical treatment of chronic duodenal obstruction, in particular, turning off the duodenum from the passage of food and the formation of the gastrointestinal and duodenojejunal anastomoses.

Along with therapeutic methods for treating chronic duodenal obstruction, there are also surgical (operative) ones, which include resection (excision) of a part of the stomach, turning off the duodenum from the food passage, after which the patency of the gastrointestinal tract is restored in various ways.

There is a method of turning off the duodenum, which consists in the fact that after excision of a part of the stomach, the duodenal stump is sutured tightly and peritonized, the remaining part (stump) of the stomach is connected to the small intestine (Billroth-2). Anastomosis is formed along the resection line near large curvature (Hofmeister, 1911, Finstiner, 1914), along the entire resection line (Reichel-Polia) (I. Littmann, “Abdominal Surgery”, Hungarian Academy of Sciences, Budapest, 1970, p. 222) - [1] or by great curvature (VA Malkhasyan. Doctoral dissertation. “Some issues of anastomosis after gastrectomy”. Yerevan, 1959) - [2].

Without taking into account the functional features, a disadvantage of the known methods for shutting down the duodenum is that the formation of the gastrointestinal anastomosis is performed by the open method, a two-row suture, the inner row of which captures all layers of anastomosed organs. This leads, firstly, to contamination of the surgical field, and secondly, to anastomosites, since all layers of the wall of anastomosed organs are captured in the internal suture, which leads to a violation of the intra-wall blood flow in the anastomotic lip, and thirdly, the epithelization of the anastomosis with this method is slowed down . In addition, a typical complication of these methods are postoperative reflux gastritis and afferent loop syndrome. With persistent ectasia of the duodenum with its atony and sagging of its lower horizontal branch with these methods, inadequate emptying of the duodenum takes place.

For comparison with the claimed method of shutting down the duodenum with chronic duodenal obstruction, a method of shutting down the duodenum is taken, which consists in the fact that after excision of a part of the stomach, suturing and peritonization of the stump of the duodenum, the remaining part of the stomach (stump) is connected to the small intestine with a long loop anastomosis according to Balfur and in addition, duodenoeunioanastomosis with the leading loop of the small intestine is formed (Mirzaev AP “Duodenal stasis. Leningrad,“ Medicine ”, 19 76, p.176.) - [3].

The disadvantages of the existing method are:

- contamination of the surgical field,

- anastomositis,

- delayed epithelization of the anastomosis,

- reflux gastritis of the stump of the stomach,

- slow recovery of motor evacuation function.

The technical result to which the invention is directed is to increase the efficiency of shutting down the duodenum with chronic duodenal obstruction: adequate drainage of the duodenum, reducing contamination of the operative field, anastomositis, accelerating the epithelization of anastomosis, faster restoration of motor-evacuation function and prevention of reflux gastritis stump of the stomach and afferent loop syndrome.

The technical result is achieved by the fact that in the method of shutting down the duodenum with chronic duodenal obstruction, including mobilizing the stomach along the greater and lesser curvatures to the previously planned resection line, flashing the duodenum below the pyloric pulp and cutting it off the stomach along the upper edge of the suture, immersing the duodenum purse string suture and its peritonization, stitching of the stomach along the resection line from small to large curvatures, cutting off the distal part of the stomach below the suture, ne ritonization of the gastric stump with sero-muscular sutures and the application of an anastomosis between the loop of the small intestine and the large curvature of the gastric stump, it is new that the formation of anastomoses is carried out between the stump of the stomach along a large curvature and a short loop of the small intestine laid in the isoperistaltic direction by electrocoagulation without opening the lumen organs with a single-row serous-muscular suture, intersection of the initial loop of the jejunum with preservation of the blood circulation of the graft, peritonization of the caudal con and disconnected bowel anastomosis between the end cross-oral gut distal part of the jejunum, creating duodenoeyunoanastomoza between the lower horizontal part of the duodenum and disconnected from the act digestion graft jejunum to achieve batch, stump rhythmic the emptying of the stomach and to avoid deficiency of bile acids.

The invention is illustrated in Fig.1-4, where:

1 - a stump of the stomach;

2 - line of great curvature of the stomach;

3 - line of lesser curvature of the stomach;

4 - resection line;

5 - angle of the stump of the stomach

6 - a stump of a duodenum;

7 - small intestine;

8 - line stitching the stump of the stomach and the loop of the small intestine;

9 - holes formed after coagulation;

10 - half-mesh seams;

11 - loop of the jejunum turned off along Ru;

12 - inter-intestinal anastomosis "end to side";

13 - transverse duodenojejunostomy.

The method of shutting down the duodenum is as follows. The stomach 1 is mobilized along the large 2 and small 3 curvatures to the previously designated resection line 4. The duodenum 6 below the pyloric pulp is stitched with a mechanical suture (for example, using the UO-40 apparatus) and cut off from the stomach 1 along the upper edge of the suture. The duodenal stump 6 is immersed in a purse string suture and peritonized. Then, along the intended resection line 4, from small 3 to large 2 curvatures, the stomach 1 is sutured. The distal part of the stomach 1 is cut off below the suture. The stump of the stomach 1 along the line of resection 4 is peritonized with serous-muscle sutures. The stump of the stomach 1 is mobilized along a large curvature 2 from the angle of the stump 5 and above for 7.0-8.0 cm. Moreover, each vessel along the posterior and anterior walls of the stomach 1 is ligated and cross separately, highlighting the posterior and anterior walls of the stomach between the subsidized vessels 1 vascular zone 1.5-2.0 cm wide. After that, to the back wall of the stump of the stomach 1 along a large curvature 2 from the angle of the stump of the stomach 5 and above, departing from the line of large curvature 2 by 1.8-2.0 cm, by over 5.0-6.0 cm sew a loop of the small intestine 7 with a single-row serous-muscular suture 8. A loop of the small intestine 7 get along in the isoperistaltic direction. Retreating 0.4-0.5 cm from the applied suture 8, the serous and muscle layers coagulate, starting from the stump angle 5 and above for 3.5-4.0 cm. The mucous layer is coagulated without opening the lumen (Shaimardanov R.Sh ., Kupkenov MA Patent for invention No. 2212196 "Lower horizontal electrosurgical gastrointestinal anastomosis", 2003.09.12) - [4]. At the same distance and in the same order, the wall of the sewn-in small intestine 7 is coagulated without opening the lumen. Two half-mesh sutures 10 are applied and tightened at the corners of the openings 9 with the capture of the stump of the stomach 1 and small intestine 7. The walls of the stump of the stomach 1 and the anastomosed loop of the small intestine 7 between the half-mesh sutures 10 are sutured with a single-row serous-muscular suture, forming the anastomosis anterior lip. After suturing, the coagulated mucous layers of the stump of the stomach 1 and small intestine 7 are crushed by palpation through the walls of the small intestine 7, after which the patency of the anastomosis is additionally controlled by a gastric tube. The loop of the small intestine is mobilized according to Ru, the initial loop of the jejunum is crossed, retreating 25-30 cm from the tracheal ligament, and a graft with good blood circulation of 35-40 cm is created 11. The caudal end of the disconnected intestine is sutured tightly and peritonized with a purse string suture. The oral end of the crossed intestine is anastomosed with the distal part of the jejunum according to the “end to side” type at a distance of 40 cm from the caudal end 12, i.e. form a mobile transplant of a jejunum 35-40 cm long, disconnected from the act of digestion. A duodenoeunoanastomosis is created between the lower horizontal part of the duodenum and the transplant of the jejunum transformed from the digestive act according to the “side to side” type 13. At the same time, the wall of the small intestine is coagulated, without opening its lumen, in the longitudinal direction for 1.5-2.0 cm , and the wall of the duodenum along the same length in the transverse. After applying the first row of sutures, the coagulated mucous layers of the duodenum 6 and small intestine 11 are crushed by palpation through the walls of the small intestine 11.

Thus, the proposed method for shutting down the duodenum in case of chronic duodenal obstruction without opening the lumen of the anastomosed organs and applying an additional duodenojunoanastomosis on the loop of the small intestine turned off along the Ru solves the problem of adequate drainage of the duodenum, reducing the pollution of the operative field, and anastomosis of anastenitis and reflux disease gastritis stump of the stomach.

Claims (1)

The method of shutting down the duodenum in case of chronic duodenal obstruction, mobilizing the stomach along the greater and lesser curvatures to the previously planned line of resection, stitching the duodenum below the pyloric pulp and cutting it from the stomach along the upper edge of the suture, immersing the duodenum and periectum , stitch the stomach along the resection line from small to large curvatures, cut off the distal part of the stomach below the suture, peritonize the stump of the stomach with serous-muscular with sutures and impose an anastomosis between the loop of the small intestine and the large curvature of the stomach, characterized in that they form an anastomosis between the stump of the stomach along the greater curvature and the short loop of the small intestine, which is laid in the isoperistaltic direction, using electrocoagulation without opening the lumen of the anastomosed organs with single-row serous-mouse a suture, moreover, they cross the initial loop of the jejunum with the creation of a graft with preservation of blood circulation, peritonize the caudal end of the disconnected intestine, form anas tomosis between the oral end of the crossed intestine and the distal part of the jejunum creates duodenojejunostomy between the lower horizontal part of the duodenum and the jejunum transplant is removed from the digestion.

Images