RU2476164C1 - Method of duodenoplasty in case of chronic ulcer of duodenal bulb, complicated with decompensated stenosis and penetration into intrapancreatic part of common biliferous duct - Google Patents

Method of duodenoplasty in case of chronic ulcer of duodenal bulb, complicated with decompensated stenosis and penetration into intrapancreatic part of common biliferous duct Download PDF

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RU2476164C1
RU2476164C1 RU2012101735/14A RU2012101735A RU2476164C1 RU 2476164 C1 RU2476164 C1 RU 2476164C1 RU 2012101735/14 A RU2012101735/14 A RU 2012101735/14A RU 2012101735 A RU2012101735 A RU 2012101735A RU 2476164 C1 RU2476164 C1 RU 2476164C1
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ulcer
common
duct
biliferous
duodenum
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RU2012101735/14A
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Russian (ru)
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Владимир Моисеевич Дурлештер
Мурат Тамерланович Дидигов
Иван Борисович Уваров
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Государственное бюджетное образовательное учреждение высшего профессионального образования "Кубанский государственный медицинский университет" Министерства здравоохранения и социального развития Российской Федерации (ГБОУ ВПО КубГМУ Минздравсоцразвития России)
Владимир Моисеевич Дурлештер
Мурат Тамерланович Дидигов
Иван Борисович Уваров
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Abstract

FIELD: medicine.
SUBSTANCE: invention relates to surgery and can be applied for duodenoplasty in case of chronic ulcer of posterior wall of duodenal (D) bulb, complicated with decompensated stenosis and penetration into intrapancreatic part of common biliferous duct. After duodenotomy posterior D wall is separated from ulcer crater, and tissues, affected with scarring or ulcer, are ablated sparingly with obligatory preservation of pylorus. Through defect of intrapancreatic part of common biliferous duct nipple polychlorovinyl 6-7 cm long drainage with 1.0-1.2 mm diameter is introduced and passed into supraduodenal part of common biliferous duct. Second end of drainage is left in D lumen and fixed with separate interrupted sutures with monolithic thread.
EFFECT: method makes it possible to reduce risk of necroses, reduce risk of suture failure.
1 ex, 5 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used in gastroenterology for the surgical treatment of patients with duodenal ulcer (duodenal ulcer) complicated by decompensated stenosis and penetration into the intrapancreatic part of the common bile duct.

In the general structure of complicated forms of duodenal ulcer, the frequency of stenosis varies from 10 to 63.5%, averaging 15-30%, the frequency of decompensated stenosis is from 5 to 15%. Among other complications of duodenal ulcer, stenosis is an indication for surgical treatment in 45-84% of patients. Mortality in the surgical treatment of decompensated stenosis is 1.5-2 times higher than in uncomplicated duodenal ulcers. With extensive ulcers of the duodenal bulb, there is often penetration of ulcers into nearby organs (pancreas, left lobe of the liver, transverse colon, common bile duct), which creates significant technical difficulties when performing surgical intervention, often requiring non-standard decisions in choosing the method of plastic reconstruction of the bulb KDP. Thus, the optimization of surgical treatment of decompensated scar-ulcer stenosis of the duodenum, the search for new methods for performing organ-preserving aids for “complex” ulcers is an urgent problem in modern surgical gastroenterology that needs to be addressed.

Stomach resection is the classic and most common method of surgical treatment of decompensated scar-ulcerative duodenal ulcer.

A known method of tubular resection of the stomach proposed by Century. Sumin (Sumin VV "Tubular resection of the stomach." Izhevsk. Publishing house of the Udmurt University, 1997 - 122 s). The essence of the method is as follows:

1) mobilization of the stomach along the greater and lesser curvature, mobilization of the duodenal bulb;

2) the intersection of the stomach in the transverse direction from the side of great curvature at a point corresponding to its half. This step can be performed using or without staplers;

3) cutting out a tubular stump of the stomach with or without staplers. In this case, the gastric dissection line should repeat the outlines of great curvature;

4) isolation of the resected part of the stomach with coarse clamps and its clipping below the zone of duodenal stenosis;

5) the formation of gastroduodenal or gastrojejunal anastomosis.

The main disadvantages of the method are the destruction of the pylorus, impaired gastric digestion and motor-evacuation function of the stomach. In addition, like other types of gastric resection, the method is accompanied by the development of post-gastro-resection syndromes (dumping syndrome 2.8%, dyspeptic disorders 3.5%, “small stomach syndrome” 5.1%).

The closest analogue is the method of surgical treatment of postbulbar duodenal ulcer with penetration into the wall of the common bile duct, proposed by A.Ya. Korovin and S.B. Bazlov (RF patent No. 2157661 from 10.20.2000). The essence of the method consists in performing a transverse postbulbar duodenotomy in order to clarify the localization of the ulcer from the lumen of the duodenum. Under the control of vision, scar-changed tissues are excised with the elimination of cicatricial deformities and cutting out a flap of the anterior-outer wall of the duodenum congruent with an ulcerative crater or a defect of the common bile duct, without crossing its transverse marginal vessels and without separating it from the outer semicircle of the ulcer crater. The formed flap is carefully adapted to the defect of the common bile duct wall, then it is hemmed along the perimeter with single-row atraumatic interrupted sutures using precision technique. The distal and proximal ends of the duodenum are mobilized with the formation of duodeno-duodenoanastomosis with single-row interrupted sutures. In all cases, decompression of the biliary tract was performed.

The disadvantages of the method include the technical complexity associated with the need to cut a flap of the wall of the duodenum on the supply leg, the possibility of necrosis, a higher likelihood of developing insolvency of the duodenal suture due to the lack of peritonization of the suture line by the strand of the greater omentum.

Tasks

Improving the immediate and long-term results of surgical treatment of patients with duodenal bulb ulcers complicated by decompensated stenosis and penetration into the intrapancreatic part of the common bile duct, reducing the number of postoperative complications, reducing postoperative mortality, and shortening bed days.

The essence of the invention is the following: after duodenotomy, the back wall of the duodenum is separated from the crater and the lesions affected by the scar or ulcer are removed sparingly with the preservation of the pylorus, then through the defect of the intrapancreatic part of the common bile duct the nipple polyvinyl chloride drainage is introduced, 6-7 cm long and 1.0- 1.2 mm, which is carried out in the supraduodenal section of the common bile duct, and the second end of the drainage is left in the lumen of the duodenum and fixed with a separate monolithic suture, then back a strand of the greater omentum is let down on the nasal wall of the duodenum and a precision single-row serous-muscular-submucosal suture is applied with a monolithic thread.

The technical result of the invention is to improve the immediate and long-term results of the treatment of patients with bulbar duodenal ulcers complicated by decompensated stenosis and penetration into the intrapancreatic part of the common bile duct by staging and preserving the pylorus, motor-evacuation function of the stomach, healing of the duodenal wound by the type of primary tension due to the formation of primary tension precision suture, reduction in the number of inconsistencies of the posterior lip of the anastomosis, the formation of bile fistulas under conditions demucosation partial posterior wall of duodenum preserving gastric digestion process in these patients. The results were confirmed in 18 patients with this pathology, there were no fatal outcomes, the average length of hospital stay decreased by 15%, and no postoperative complications were observed.

The method is shown in figures 1-5, where

Fig. 1 - Stage of transverse duodenotomy through the stenosis zone.

Fig. 2 - Nipple drainage is carried out through the defect into the common bile duct.

Fig. 3 - Summing a lock of a large omentum under an anastomosis.

Fig. 4 - Application of a precision suture on the posterior lip of the anastomosis. Drainage was carried out in the lumen of the duodenum and fixed with a single nodal suture.

Fig. 5 - The final type of operation. Superimposed cholecystostomy for decompression.

Pos. 1 - Crater penetrating into the intrapancreatic part of the common bile duct ulcer.

Pos. 2 - Nipple drainage.

Pos. 3 - Strand of a large omentum.

Pos. 4 - Precision single-row serous-muscular-submucosal duodenal suture.

Pos. 5 - Drainage is carried out in the lumen of the duodenum and is fixed with one suture.

Pos.6 - Unloading cholecystostomy.

Pos. 7 - KDP.

Pos. 8 - common bile duct.

The method is as follows. After performing a median laparotomy and correcting access with Sigal dilators, they begin an intraoperative examination (diagnosis) in the duodenogastric zone. Perform a phased allocation of the affected area from cicatricial adhesions, finding dilated non-functioning pylorus. Then produce transverse duodenotomy through the area of bulbar stenosis. After differentiation of the pylorus, the large duodenal nipple (BDS), they begin to excise the walls of the duodenal bulb affected by a scar or ulcer (item 7). This is done extremely economically, preserving the intact intestinal tissue as much as possible, especially in the pyloric zone. The operation is performed only in the zone of altered tissues on the affected intestine, since the displacement and expansion of the excision zone can lead to damage to the elements of the hepatoduodenal ligament, pancreatoduodenal artery, pancreas. The penetrating ulcer of the duodenal bulb is removed from the lumen of the organ, treated with a Volkman spoon (item 1). In the defect of the intrapancreatic part of the common bile duct (pos. 8), nipple polyvinyl chloride drainage is introduced, 6-7 cm long and 1.0-1.2 mm in diameter, which is carried out into the lumen of the duodenum (pos. 2) and fixed with a single nodal suture with a monolithic thread ( pos. 5), after which the strand of the greater omentum is brought under the back wall of the duodenum (pos. 3), then a single-row serous-muscular-submucous seam of the duodenum is formed with a monolithic thread (pos. 4). The final stage of the operation is the application of an unloading cholecystostomy (item 6). Using this technique allows you to achieve healing of the duodenal wound by the type of primary tension without marginal necrosis of the mucosa with the formation of a tender scar.

Clinical example. Patient N., 66 years old, was admitted to the admission department of the MUZ GB No. 2 in an extremely serious condition. Confused consciousness, twitching of the muscles of the upper and lower extremities. Skin turgor is sharply reduced. In the lungs, hard breathing, respiratory rate of 24-26 per minute. Pulse 100 beats per minute, rhythmic, weak filling. Blood pressure 90/60 mm Hg There was moderate soreness on palpation in the epigastric region and a “splash” noise. From laboratory data, anemia (er. 2.4 T / L, Hb 80 g / L, CP 1.0), hypoproteinemia (total protein 45 g / L) was noted. Based on the history, laboratory and instrumental examinations (ultrasound, FGDS), a diagnosis was made - duodenal ulcer, complicated by decompensated stenosis with symptoms of true gastrogenic tetany. After appropriate preoperative preparation, the patient was operated on. After performing a laparotomy, an intraoperative study was performed, it was found that tubular stenosis of the duodenal bulb was observed for 3 cm. The affected area was phased out from cicatricial adhesions, and the dilated nonfunctioning pylorus was found. Then transverse duodenotomy was made through the area of bulbar stenosis. A chronic ulcer of the posterior wall of the duodenal bulb 1.5 × 1.0 cm with penetration into the intrapancreatic part of the common bile duct was found. After differentiation of the pylorus, BDS, the walls of the duodenal bulb, scarred, were excised, the ulcer was removed from the lumen of the duodenum, and treated with a Volkman spoon. This is done extremely sparingly, preserving intact intestinal tissue as much as possible, especially in the pyloric zone. Polyvinyl chloride perforated drainage up to 6 cm long was introduced into the supraduodenal part of the common bile duct through the defect in the ulcer penetration zone, introduced into the lumen of the duodenum, fixed with a separate nodal suture with a monolithic thread. Under the back wall of the duodenum bulb, a strand of a large omentum is laid. Then a single-row serous-muscular-submucosal suture was formed with a monolithic thread under the conditions of precision technology. Surgery is completed by the formation of discharge cholecystostomy. The postoperative course is smooth. On the 5th day after the operation, the volume of an empty stomach was 300 ml. In a satisfactory condition, the patient was discharged for outpatient treatment on the 12th day after surgery. The long-term result is tracked one year after the operation. Disability is fully restored, no complaints, diet does not comply, no recurrence of ulceration. According to the X-ray examination, portioned evacuation from the stomach was preserved with its complete emptying within an hour and a half.

Claims (1)

  1. Method of duodenoplasty in case of chronic ulcer of the posterior wall of the duodenal bulb (duodenum) complicated by decompensated stenosis and penetration into the intrapancreatic part of the common bile duct, including mobilization of duodenum and transverse duodenotomy, which differs from duodenosis with duodenotomy affected by a scar or ulcer tissue with the preservation of the pylorus, then through the defect of the intrapancreatic part of the common bile duct in nipple polyvinyl chloride drainage is driven 6-7 cm long and 1.0-1.2 mm in diameter, which is carried out in the supraduodenal section of the common bile duct, and the second end of the drainage is left in the lumen of the duodenum and fixed with a separate nodal suture with a monolithic thread, after which under the back wall KDP lead a strand of a large omentum and impose a precision single-row serous-muscular-submucosal suture with a monolithic thread.
RU2012101735/14A 2012-01-18 2012-01-18 Method of duodenoplasty in case of chronic ulcer of duodenal bulb, complicated with decompensated stenosis and penetration into intrapancreatic part of common biliferous duct RU2476164C1 (en)

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Citations (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
RU2157661C2 (en) * 1997-06-04 2000-10-20 Коровин Александр Яковлевич Surgical method for treating bleeding postbulbar duodenal peptic ulcer penetrating common bile duct wall
EP2103222A1 (en) * 2008-03-20 2009-09-23 Meyn Food Processing Technology B.V. Method and apparatus for mechanically processing an organ or organs taken out from slaughtered poultry

Patent Citations (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
RU2157661C2 (en) * 1997-06-04 2000-10-20 Коровин Александр Яковлевич Surgical method for treating bleeding postbulbar duodenal peptic ulcer penetrating common bile duct wall
EP2103222A1 (en) * 2008-03-20 2009-09-23 Meyn Food Processing Technology B.V. Method and apparatus for mechanically processing an organ or organs taken out from slaughtered poultry

Non-Patent Citations (3)

* Cited by examiner, † Cited by third party
Title
PUPKA A. et al. The use of synthetic vascular prosthesis in the surgical treatment of secondary aorto-duodenal fistulas. Polim Med. 2004; 34(1):3-12 (Abstract). *
КЛИМОВ А.Е. и др. Обучение основным методам хирургических вмешательств на органах билиопанкреатодуоденальной области, принципам прецизионного шва желчных протоков и панкреатикодигестивных анастомозов. - М., 2008, с.3, 4. *
КЛИМОВ А.Е. и др. Обучение основным методам хирургических вмешательств на органах билиопанкреатодуоденальной области, принципам прецизионного шва желчных протоков и панкреатикодигестивных анастомозов. - М., 2008, с.3, 4. PUPKA A. et al. The use of synthetic vascular prosthesis in the surgical treatment of secondary aorto-duodenal fistulas. Polim Med. 2004; 34(1):3-12 (Abstract). *

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