RU2479261C2 - Pyloroplasty procedure in patients with type three gastric ulcers - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and may be applicable for pyloroplasty in patients with type III gastric ulcers. Stomach is dissected transversally to its longitudinal axis by two semi-oval incisions at max. 2.0 cm from the pylorus and by partial excision of the pyloric sphincter.

EFFECT: procedure enables preserving innervation and motor-evacuation function.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to the surgical treatment of type III gastric ulcers complicated by bleeding or perforation.

In clinical practice, classical methods of pyloroplasty according to Heineke-Mikulicz or Finney are widely used in patients with complicated stomach ulcers of type III (classification by H. D. Johnson, Johnson HD Gastric ulcers, blood groups and acid secretion / HDJohnson, AHGLove, NCRoders, APWyatt // Gut. - 1964. - Vol.5. - P.402-411), which are combined with various variants of vagotomy.

The disadvantage of these methods is the significant destruction of the pylorus, which is accompanied by a pronounced violation of the motor-evacuation function of the stomach when combined with various types of vagotomy (stem, selective, selective proximal vagotomy). Especially these shortcomings are manifested when performing stem or selective vagotomy.

The use of selective proximal vagotomy using these types of pyloroplasty also leads to disruption of the motor-evacuation activity of the antrum.

The reason for such violations is due to the fact that the length of the cut of the duodenum and stomach during pyloroplasty according to Heineck-Mikulich is at least 6.0 cm (2.5 cm section of the duodenum and 3.5 cm section on the stomach) (Cooperman, A.M. Pyloroplasty / A.M. Soorerman, S.O. Hoerr // Surg. Clin. North Amer. - 1975. - Vol.55. - P.1019-1024).

When pyloroplasty is performed according to Finney, gastroduodenoanastomosis is formed after the pyloric intersection, and the length of the incision on the stomach and duodenum should be at least 5.0 cm, which virtually eliminates the participation of the antrum in motor activity.

Based on anatomical studies, it is known that the length of the antrum (antrum pyloricum) is normally no more than 7.0 cm (Griffith, C. A. Anatomy of the stomach and duodenum / CAGriffith, C. Wastell, L. M. Nyhus , PEDonahue // Surgery of the Esophagus, Stomach and Small Intestine. - 5th ed. - Boston: Little, Brown and Co, 1995. - P.388-417), and the motor innervation of the pyloric sphincter is carried out including the “goose foot ”of the anterior nerve Laterje. Thus, when performing pyloroplasty according to Heineck-Mikulicz or Finney, the branches of the “goose paw” of the Laterje nerve often intersect, which is accompanied by denervation of the pyloric sphincter.

The objective of the invention is to preserve the innervation of the antrum and motor-evacuation activity of the stomach.

The problem is solved by the method of pyloroplasty, which includes the dissection of the stomach in the transverse direction to its longitudinal axis by two vertical semi-oval sections no more than 2 cm from the pylorus and partial excision of the pyloric sphincter. A similar incision allows excision of a perforated ulcer or a bleeding ulcer of the antrum located on the back wall (frequent localization of complicated stomach ulcers of type III).

The method is as follows, after a laparotomy, a cross section of the stomach is made in relation to the longitudinal axis along the muscle fibers in the antrum at a distance of not more than 2.0 cm from the pylorus with additional excision (with subsequent stitching in the vertical direction) of the stomach wall with semi-oval sections with partial excision of the pyloric sphincter and excision of an ulcer of the posterior wall of the antrum.

The proposed method of pyloroplasty can significantly reduce the length of the incision, which is used with classical pyloroplasty, preserves the innervation of the antrum (the branches of the goose foot of the anterior nerve Latarje are not damaged) and creates a sufficient diameter of the pyloroplasty (excision of the pyloric sphincter for 1.0 cm - partial preservation functions), which allows you to save the innervation of the antrum, creates a sufficient postoperative lumen of the intestinal tube, which is not accompanied by a violation I have a motor-evacuation activity of the stomach.

This method of pyloroplasty is quite simple, accessible to most surgeons, retains the advantages of proximal gastric vagotomy or its variants and can improve the results of surgical treatment of patients with gastric ulcer type III with various complications (perforation of an ulcer or bleeding).

The method is illustrated in Fig. 1, where A, B, C, D are the stages of the operation.

CLINICAL EXAMPLE

Patient T.F.M., 46 years old, was admitted to the hospital surgery clinic No. 2 on the basis of Clinical Hospital No. 79 with complaints of nausea, vomiting of gastric contents with an admixture of blood, weakness, dizziness. The patient's condition is serious. The skin is pale. Vesicular respiration in the lungs, respiratory rate 26, blood pressure 90/50 mm Hg; pulse 118, rhythmic, weak filling and tension. The abdomen is not swollen, it symmetrically participates in the act of breathing, with palpation it is soft and painless in all departments. Hepatic dullness saved. Pasternatsky’s symptom is negative on both sides. Urination is free, painless. In the study of per rectum - melena.

In the intensive care unit, the patient underwent an emergency EFGDS, in which an ulcer of the prepiloric stomach was revealed along the back wall up to 2 cm in diameter, the bottom of which was made with a fresh blood clot, from which fresh blood flows (Forest IB). An attempt at endoscopic hemostasis, in which a blood clot was removed, without effect, increased bleeding was noted. Thermocoagulation, injection of norepinephrine at the base of the ulcer, the use of fibrin glue had no effect. Given the inefficiency of endoscopic hemostasis, the patient urgently performed surgery after a short preoperative preparation. Taking into account the low risk of death on the basis of the forecast proposed in the hospital surgery clinic No. 2, the patient underwent surgery: laparotomy, transverse section of the stomach along the longitudinal axis along the muscle fibers in the antrum at a distance of not more than 2.0 cm from the pylorus with additional excision (with subsequent stitching in the vertical direction) of the stomach wall by semi-oval incisions with partial excision of the pyloric sphincter in combination with the proximal eludochnoy vagotomy with excision of the posterior wall ulcers, gastric antrum. The postoperative period was uneventful. When examining the patient after a year: the condition is satisfactory, no complaints.

Claims (1)

The method of pyloroplasty in patients with type III gastric ulcers, which consists in cutting the stomach in the transverse direction to its longitudinal axis with two semi-oval incisions at a distance of not more than 2.0 cm from the pylorus and partial excision of the pyloric sphincter.

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