RU2463969C1 - Method of operative treatment of patients with complicated ulcer disease of stomach and esophagus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for operative treatment of patients with complicated ulcer disease of stomach and esophagus. Laparoscopy, during which diameter of perforated opening and length of inflammatory infiltrate from edges of perforated opening are measured, is performed. On the basis of obtained data perforated ulcer is classified in the following way: if diameter of perforated opening. ≤ 2 mm, I class is determined, >2 mm and ≤5 mm - II class, >5 mm and ≤10 mm - III class, >10 mm - IV class; if measured length of inflammatory infiltrate is ≤5 mm, class A is determined, if it is >5 mm and ≤10 mm - class B, if it is >10 mm - class C. On the basis of determined classes methodology of laparoscopic suturing of perforated ulcer is selected and performed: in case of IA, IB and IIA class opening is sewn with one Z-shaped suture with absorbable thread; in case of IC or IIB class, opening is sewn with separate one-row sutures with absorbable thread, in case of IIC, IIIA or IIIB class, opening is sewn with separate two-row sutures: the first row with absorbable thread, the second row with non-absorbable thread, in case of perforated gastric ulcer of IIIC, IVA, IVB or IVC class, opening is sewn with separate two-row sutures: the first row with absorbable thread, the second row with non-absorbable thread, then terminal branch of left trunk of vagus nerve is visualised - Latarget nerve and selective proximal vagotomy is performed from proximal Latarget nerve towards esophagus on small curvature by means of ultrasonic scissors.

EFFECT: method makes it possible to reduce risk of recurrence, ensure early regeneration of tissues

2 ex

Description

The invention relates to medicine, namely to laparoscopic access surgery.

Despite the significant success of conservative treatment of duodenal ulcer (duodenal ulcer), almost half of the patients develop life-threatening complications over time. A formidable and life-threatening complication is ulcer perforation. According to the literature, peptic ulcer of the duodenum occurs in 7-15% of the working population, and the frequency of perforations of gastroduodenal ulcers is about 1.5-2 people per 10 thousand of the working population. In the structure of acute surgical pathology of the abdominal cavity, this complication is 1.9-2.6%. Mortality in perforated ulcers remains high, has no tendency to decrease, especially in older people and amounts to 5-15% (Belov I.I. 2004; W.T.Siu, H.T. Leong, Law et al. 2002).

The operation of choice during perforation of gastroduodenal ulcers remains suturing of the perforated hole and drainage of the abdominal cavity. However, this operation is forced and does not eliminate the conditions for perforated ulcers. After suturing, the threat of relapse is possible even against the background of antiulcer therapy due to, on the one hand, the fact that peeling of the perforated hole does not eliminate the main ulcer formation factor - peptic, on the other hand - surgical intervention inevitably leads to the development of irreversible anatomical changes in the suturing area and first of all - circulatory disorders in the duodenum. Thus, according to various authors, complications arise in 25-70% of patients with sutured perforated ulcers, which require a repeated radical operation in 22-35% of cases.

Thus, the choice of the method of surgical treatment in patients with a chronic complicated duodenal ulcer is still one of the urgent problems of surgical gastroenterology. The development of modern minimally invasive technologies has stimulated the development of new organ-preserving methods for the surgical treatment of chronic complicated duodenal ulcers (Aleshkovsky L.A., 2006), which allow achieving a permanent cure with minimal trauma (Lutsevich, 2003).

One of the methods used in the treatment of perforated duodenal ulcers is an operation consisting of suturing a perforated hole in combination with a laparoscopic superselective vagotomy (C. Grassi), (prototype of the claimed method - A. A. Kurygin, V. V. Rumyantsev. Vagotomy in surgical gastroenterology. St. Petersburg, 1992. - 152 p.). After suturing the perforated hole, a selective proximal vagotomy is performed, in which the proximal branches of the vagus nerves innervating the body and the arch of the stomach are intersected directly at their entry into the wall of the stomach. This operation provides the denervation of all acid-pepsin-producing fields of the stomach while maintaining the innervation of the pyloric pulp and its function due to Latarge's nerves. However, the performance of this operation in its open modification leads to the development of postoperative complications associated with both the features of the operation and the trauma of surgical access (suppuration of the postoperative wound, intraperitoneal infiltrates and abscesses, inconsistency of sutures in the perforated opening, early adhesive intestinal obstruction, pulmonary complications ) The total frequency of complications, according to the author of the prototype of the claimed method, reaches 4.6%.

In connection with this, a modification of this operation is proposed, the task of which is to reduce the number of these complications both by choosing the closure method based on the developed classification of perforated ulcers and by performing the entire operation in a laparoscopic manner.

Achievable in the proposed method, the technical results are:

- minimization of surgical trauma, which in the postoperative period manifests itself in the form of a less pronounced pain syndrome, early activation of patients, early resolution of postoperative rupture of the intestine, reduction in the need for narcotic analgesics, antibacterial drugs and infusion therapy, a decrease in the risk of postoperative complications, and a reduction in the time of inpatient treatment of patients ;

- minimizing the risk of recurrence of peptic ulcer disease, such as repeated perforation and bleeding, which is provided by the simultaneous treatment of complications of peptic ulcer disease (perforation) with the elimination of the main factor of ulcer formation - peptic;

- ensuring an adequate choice of the method of suturing perforated ulcers based on the developed classification of perforated ulcers, which minimizes the risk of insolvency and other intra-abdominal complications due to early tissue regeneration in the perforation area and the absence of perifocal inflammation.

The method is as follows.

Diagnostic laparoscopy is performed in order to clarify the diagnosis and select operative tactics after additional examination. When the diagnosis is verified and there are no contraindications, the perforated hole is sutured and the abdominal cavity is sanitized. Why laparoscopy is performed, during which the diameter of the perforated hole and the length of the inflammatory infiltrate from the edges of the perforated hole are measured. Based on the data obtained, a perforated ulcer is classified, namely:

- with a hole diameter of ≤2 mm, class I is established,

-> 2 mm and ≤5 mm - II class,

-> 5 mm and ≤10 mm - III class,

-> 10 mm - IV class;

- with a measured length of inflammatory infiltrate ≤5 mm, class A is established, with> 5 mm and ≤10 mm - class B, with> 10 mm - class C.

Then, based on the revealed classes, the technique of laparoscopic suturing of the perforated ulcer is chosen:

- with classes IA, IB or IIA, the hole is sutured with one “Z” -shaped suture with an absorbable thread;

- with classes IC or IIB, the hole is sutured with separate single-row sutures with absorbable thread;

- with classes IIC, IIIA or IIIB, the hole is sutured with separate two-row seams: the first row - with absorbable thread; second row - non-absorbable thread;

- with a perforated stomach ulcer of class IIIC, IVA, IVB or IVC, the hole is sutured with separate two-row sutures: the first row - with an absorbable thread; second row - non-absorbable thread;

- with a perforated ulcer of the duodenum of class IIIC, IVA, IVC, laparoscopic suturing of the perforated hole is not shown (larger open surgery is necessary - gastric resection, pyloroplasty and others).

In the event that there is a perforated ulcer of the duodenum of class IIIC, IVA, IVC, an open operation is performed and selective vagotomy is not performed. Even if a vagotomy is performed, it will not be selective.

Next, the terminal branch of the left (anterior) vagus nerve trunk (Latarge branch) is visualized, which innervates the acid-reproducing zone of the stomach. Selective proximal vagotomy is performed from the proximal branch of Latarget towards the esophagus along the lesser curvature using ultrasound scissors (e.g. Ultracision, Ethicon, USA). The operation ends with drainage of the abdominal cavity.

Clinical example No. 1. Patient L., 39 years old. Clinical diagnosis: Perforated duodenal ulcer (IIB). He was admitted with complaints of severe pain in the epigastric region, in the right half of the abdomen, cold sweat.

X-ray of the chest and abdomen upon admission: Pulmonary fields are transparent. The roots are structural. Hydropneumothorax was not detected. The shadow of the heart is not expanded. Free gas under the right dome of the diaphragm. In the colon, gas, dense contents. Single loops of the small intestine containing gas in the epigastrium.

Ultrasound of the abdominal cavity upon admission: ultrasound signs of free fluid in the abdominal cavity, hepatomegaly, diffuse changes in the pancreas.

The patient underwent diagnostic laparoscopy, in which a perforated ulcer of the anterior wall of the duodenum 12 up to 5 mm in size and an inflammatory shaft 1 cm long (IIB) were revealed. The patient underwent laparoscopic suturing of the perforated ulcer of the duodenum with individual single-row sutures with absorbable suture, selective proximal vagotomy, debridement, drainage of the abdominal cavity.

The postoperative period was uneventful. Drainage tubes removed 4-5 days after surgery. Sutures were removed on the 6th day. The wounds healed by primary intention. In the postoperative period, a panoramic x-ray of the chest and abdominal cavity, ultrasound of the abdominal cavity organs, pH measurement and X-ray examination of the stomach with a contrast agent were performed.

With an x-ray of the chest and abdominal cavity and ultrasound of the abdominal organs - without pathology.

An X-ray examination of the stomach revealed no evacuation disorders.

In satisfactory condition, the patient was discharged from the surgical department.

Clinical example No. 2. Patient L., 39 years old. Clinical diagnosis: Perforated duodenal ulcer (IB). Superficial gastritis, bulbitis.

He was admitted with complaints of severe pain in the epigastric region, in the right half of the abdomen, cold sweat.

X-ray of the chest and abdomen upon admission: Pulmonary fields are transparent. The roots are structural. Hydropneumothorax was not detected. The shadow of the heart is not expanded. Free gas under the right dome of the diaphragm. In the colon, gas, dense contents. Single loops of the small intestine containing gas in the epigastrium.

Ultrasound of the abdominal cavity and kidneys upon admission: ultrasound signs of free fluid in the abdominal cavity, hepatomegaly, diffuse changes in the liver parenchyma.

The patient underwent diagnostic laparoscopy, in which a perforated duodenal ulcer of 2 mm in size and an infiltrative shaft of up to 6-7 mm was detected, which corresponded to class IB. Performed laparoscopic suturing of the perforated opening of the duodenum with one "Z" -shaped suture with absorbable suture, selective proximal vagotomy, debridement, drainage of the abdominal cavity.

In the postoperative period, the patient received antiulcer, infusion, antibacterial, antispasmodic and symptomatic therapy.

X-ray of the chest and abdomen: Pulmonary fields without focal and infiltrative shadows. Hypoventilation of the basal departments from two sides. The roots of the structure are not densified. The diaphragm is clear, usually located. Postoperative gas under the diaphragm on both sides. The stomach against the background of a nasogastric tube is not swollen. The small intestine contains practically no gas. A moderate amount of gas along the colon along the entire length, dense contents throughout.

Ultrasound of the abdominal cavity: ultrasound signs of free fluid in the abdominal cavity were not detected, diffuse changes in the liver are not observed.

X-ray of the stomach: Condition after suturing perforated ulcers of the duodenum 12. Selective proximal vagotomy. Gastric evacuation is not impaired.

In satisfactory condition, the patient was discharged from the surgical department.

Claims (1)

A method for surgical treatment of patients with complicated gastric and duodenal ulcer, including suturing the perforated hole and performing selective proximal vagotomy, characterized in that laparoscopy is performed, during which the diameter of the perforated hole and the length of the inflammatory infiltrate from the edges of the perforated hole are measured, based on the obtained data classify a perforated ulcer, namely: with a diameter of the perforated hole ≤2 mm, I class is established,> 2 mm and ≤5 mm - II class,> 5 mm and ≤10 mm - III class,> 10 mm - IV class; for a measured inflammatory infiltrate length of ≤5 mm, class A is established, for> 5 mm and ≤10 mm - class B, for> 10 mm - class C, then, based on the identified classes, a laparoscopic suturing of the perforated ulcer is selected and implemented: for classes IA, IB or IIA hole is sutured with one “Z” -shaped suture with absorbable thread; with classes IC or IIB, the hole is sutured with separate single-row seams with absorbable thread; with classes IIC, IIIA or IIIB, the hole is sutured with separate double-row seams: the first row with absorbable thread; the second row - non-absorbable thread, with a perforated stomach ulcer of class IIIC, IVA, IVB or IVC, the hole is sutured with separate two-row seams: the first row - with an absorbable thread; the second row - with non-absorbable suture, then the final branch of the left trunk of the vagus nerve is visualized - the Latarge branch and from the proximal Latarge branch towards the esophagus along the lesser curvature with the help of ultrasonic scissors, selective proximal vagotomy is performed.