RU2460479C1 - Method of treating difficult duodenal ulcer with accompanying chronic duodenostasis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for treatment of difficult duodenal ulcer with accompanying chronic duodenostasis. Resection of stomach with formation of intestinal loop in accordance with Roux is performed. Longitudinal cut on counter-mesenteric edge of jejunum is made immediately opposite duodenum stump, with approximately 10-15 cm indent from gastrojejunal anastomosis. Anastomosis is applied between duodenum stump and jejunum.

EFFECT: method makes it possible to reduce risk of duodenum stump failure.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to surgical gastroenterology, and can be used in the treatment of difficult duodenal ulcers.

It is known that the most difficult step of Billroth-II gastric resection in difficult ulcers is the closure of the duodenal stump. In the literature, one can find a description of about 200 suturing techniques, none of which guarantee protection against the development of insolvency [2]. The imposition of gastroduodenoanastomosis in conditions of uncorrected duodenostasis leads to the formation in the long term of duodeno-gastric reflux and alkaline reflux gastritis. In this regard, a number of authors propose to opt for one of the options for Billroth-2 operation. In this situation, the surgeon faces a dilemma: to complete the Billroth-2 operation and risk possible failure of the duodenal stump under duodenostasis, or perform Billroth-1 stomach resection and obtain unsatisfactory long-term results due to duodenogastric reflux [1].

There is a method of treating chronic duodenal ulcer by resection of the stomach according to Ru, characterized in that instead of closing the stump of the duodenum, a terminal-term duodenojejunoanastomiasis is formed using the free end of the intestinal loop of the gastrojejunoanastomosis according to RU and ulcerative crater filling (by application No. 14, No. 14, No. 14, No. 14, 07.07. 1997 C. A61B 17/00).

The disadvantages of the known methods are the presence of an anti-peristaltic outlet loop, the presence of which can lead to difficulty in evacuation from the stomach and an increased risk of anastomotic insolvency. The passage of food through the duodenum is completely turned off, which causes a violation of the participation of the latter in the neuro-humoral regulation of digestion and absorption. Another important drawback of the known technique is the frequent discrepancy between the diameters of the anastomosed duodenal stump and the end portion of the loop of Ru, which creates additional difficulties when applying an anastomosis.

The purpose of the invention: to reduce the incidence of insolvency of the stump of the duodenum after performing a resection of the stomach in conditions of a difficult duodenal ulcer against a background of chronic duodenal obstruction. The goal is achieved by performing a decompression duodenojejunostomy end-to-side with a single-row seam.

The modeling method is as follows: after performing a gastrectomy, an end-end gastroeyunoanastomosis is applied on a loop of Ru about 50 cm long. Then, retreating from the gastroeyunoanastomosis about 10-15 cm, immediately a longitudinal incision is made across the duodenal stump along the mesenteric edge of the jejunum, its size corresponding to the diameter of the stump. The next step is to apply a single-row anastomosis between the stump of the duodenum and the jejunum. When performing duodenoeunoanastomosis, a single-row serous-muscular-submucosal nodal suture was always used. A single-row suture allows economical mobilization of the duodenum; for its application, 5 mm of its wall is sufficient. The figure shows a loop of jejunum 1 and a stump of the duodenum 2 involved in the anastomosis (see. Fig.).

Gastric resection according to Ru with superimposed decompression end-lateral duodenojejunostomy allows solving several problems:

1. Avoid such a risky stage of surgery as a suturing of the duodenal stump in a difficult ulcer and duodenostasis.

2. To ensure a reduction in intraluminal pressure in the duodenum and, therefore, in the long-term postoperative period, stop the chronic duodenal obstruction.

3. Promote the participation of the duodenum in the digestion and neurovegetative regulation of the function of other sections of the gastrointestinal tract.

Example. Patient S., 55 years old, was admitted to the surgical department of FGU BO UFSIN in the Ryazan region. 04/03/2006, Upon admission, he complained of severe abdominal pain that appeared 6 hours before admission. No ulcerative history. For a long time suffers from chronic pancreatitis, periodically worried about herpes pain, vomiting. Objective: General condition is satisfactory. Pulse 88 in min. HELL 140/90 mm Hg The tongue is dry. The abdomen is not swollen, tense and painful in all departments. Positive symptoms of peritoneal irritation. For technical reasons, abdominal radiography is not possible. In the general analysis of blood leukocytosis 12 * 10 ¹² / L. With a diagnosis of perforated gastric ulcer, the patient was taken to the operating room.

Under general anesthesia, an upper median laparotomy was performed. In the subhepatic space, on the right flank and in the small pelvis, a moderate amount of gastric contents mixed with bile and fibrin. The front wall of the duodenal bulb is destroyed and is represented by a perforated hole with a diameter of up to 3 cm with callous edges. The stomach is connected with the duodenum with only a narrow strip of mucous membrane along the posterior wall of the bulb. Sewing perforation is not possible. It was decided to perform a resection of the stomach. A tubular stump of the stomach was formed according to the method described above. There are signs of chronic duodenostasis: dilatation and atony of the descending part of the duodenum. The pancreas is dense, sclerosed, the head is enlarged. The imposition of gastroduodenoanastomosis in this situation is contraindicated because of the high risk of developing duodeno-gastric reflux. It was decided to perform gastroejunoanastomosis on the loop of Ru. A loop of Ru 50 cm long was highlighted, an end-end gastrojejunoanastomosis with a single-row nodal atraumatic suture was applied. Reliable suturing of the duodenal stump is not possible due to tissue deficiency. Gastroejunoduodenoplasty was performed - a single-row nodal atraumatic anastomosis of the duodenal stump with a loop of the jejunum, isolated according to Ru, 15 cm below the gastrojejunoanastomosis, was applied according to the end-to-side technique. The abdominal cavity is sanitized, drained and sutured in layers. The postoperative period was uneventful. Examined after 2 years, no complaints. When FGDS signs of alkaline reflux gastritis was not found. Junoduodenoanastomosis with a diameter of about 2 cm, without signs of anastomositis.

Information sources

1. Vlasov A.P., Saraev V.V., Stepanov Yu.P., Rubtsov O.Yu. New technologies in the surgery of "difficult" duodenal ulcers. // Surgery - 2008. - No. 8. - S. 44-48.

2. Nikitin N.A. Insufficiency of sutures of the duodenal stump in urgent surgery of peptic ulcer. - Kirov: Vyatka, 2002 .-- 144 p.

3. Oskretkov V.I., Wilhelm N.P. Surgical treatment of chronic duodenal ulcer combined with chronic duodenal obstruction. // Surgery - 1998. - No. 3. - S. 41-44.

4. Sakharov V.V. The choice of the method of operation for "difficult" ulcers of the duodenal bulb (giant, penetrating): Abstract. dis. Cand. honey. sciences. - Tomsk, 2003 - 23 p.

5. Tarasenko S.V., Zaitsev O.V., Kopeikin A.A., Karyukhin I.V. A method for evaluating the long-term results of surgical treatment of diseases of the stomach and duodenum. // Bulletin of new medical technologies. - 2009. - T.XVI., No. 2. - S. 169-172.

Claims (1)

A method of treating a difficult duodenal ulcer with concomitant chronic duodenostasis is characterized in that an end-lateral single-row serous-muscular-submucosal decompression duodenoejunoanastomosis using the intestinal loop of the gastrojunoanastomosis in the Ru is performed by performing a gastrectomy with an endoastomastosis of 50 cm , a longitudinal incision along the mesenteric edge of the jejunum immediately opposite the duodenal stump, stepping back from the gastro noanastomoza about 10-15 cm, and anastomosis between the stump of the duodenum and jejunum.

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