RU2510245C2 - Method for arrest of hemorrhage from duodenal ulcer penetrating into head of pancreas - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery. An endostatic detection of a bleeding penetrating duodenal ulcer is followed by a laparotomy. An ulcer hemostasis is provided by a ligation about an ulcer substratum of anterior and posterior vascular branches of superior and inferior pancreaticoduodenal arteries.

EFFECT: method enables simplifying the technique of surgical hemostasis in bleeding duodenal ulcers penetrating into the head of pancreas.

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Description

The invention relates to medicine, to abdominal surgery, can be used to stop bleeding with a duodenal ulcer penetrating into the head of the pancreas in patients at increased risk of surgery, in elderly patients with severe concomitant diseases.

Surgical treatment of acute bleeding from duodenal ulcers penetrating into the head of the pancreas represents an urgent task of emergency surgery. With ulcerative bleeding in the elderly and senile, the use of sparing organ-preserving operations is most justified. The most common way to stop bleeding is to conduct duodenotomy with suturing of a bleeding ulcer with a ligature and suturing the latter (Savelyev BC Guidelines for emergency surgery of abdominal organs. / BC Savelyev, M.M. Abakumov, L.P. Bakuleva, etc. M .: Medicine, 1986. - S.510-511). The method is less traumatic and allows you to save the life of the patient. However, flashing of a bleeding vessel and suturing of a penetrating ulcer is often complicated by regional necrosis of ulcer tissue in the postoperative period with subsequent relapse of ulcer bleeding. Relapse of ulcerative bleeding poses an even greater danger to the lives of patients, especially in elderly people, since the mortality among them increases to 30-40% (Onopriev V.I.The position of the surgeon in the treatment of complicated duodenal ulcers and new technologies. / B. I. Onopriev // Russian Journal of Gastroenterology, Hepatology and Coloproctology, 1998. - No. 6. - P.63-70; Bushkov PN, Ulcerative gastroduodenal bleeding in the Far North. / PN Bushkov et al. // Herald of surgery, 2002. - T.161, No. 4. - S.17-19).

A known method of treating a duodenal bleeding ulcer, including duodenotomy, hemostasis, vagotomy, a stomach draining operation, in which, in order to prevent recurrence of bleeding, hemostasis is performed by suturing the free area of the omentum to the ulcer, after which the edges of the duodenotomy incision are completely invaginated over the epiploon, and the lumen is completely closed. and as a draining operation, gastroenteroanastomosis is used (SU No. 1158171, publ. 05/30/1985, IPC ⁷ A61B 17/00, A61B 17/11). The disadvantage of this method is that when using a lock of a large omentum on a leg, it is possible to develop necrosis of the omentum and insolvency of the suture line, which leads to relapse of bleeding and peritonitis.

A known method of treating bleeding gastroduodenal ulcers, in which to ensure reliable hemostasis and prevent recurrence of bleeding after gastroduodenotomy, large vessels are sutured at the bottom of the ulcer with 8-shaped sutures, the bottom of the ulcer is drained, treated with a 70% ethanol solution and filled with an adhesive composition that contains 50 -200 IU of powdered thrombin per 1 ml of glue KL-3 with the addition of a polymerization accelerator. The ulcer is sutured by ligature under its bottom, and tightened after the foaming and polymerization of the glue begins. During the tightening of the joints implantation of glue takes place (SU No. 1507349, publ. September 15, 1989, IPC ⁷ A61B 17/00, A61B 17/12, A61L 24/04). The disadvantage of this method is the limited duration of thrombin and the possibility of migration of the adhesive composition, which leads to a relapse of bleeding.

A known method of stopping bleeding with an invasive penetrating duodenal ulcer, in which a complete intersection of the duodenal ulcer is performed, which is plugged with an alloplant, then the duodenal stump is sutured, that is, the stomach is resected by Billroth 2. In this case, there is a risk of developing duodenal ulcer and the resumption of bleeding when the alloplant departs from the bottom of the ulcer (RU No. 2173100, publ. 09/10/2001 IPC ⁷ A61B 17/00, A61B 17/12).

A known method of stopping ulcerative gastroduodenal bleeding by applying clips using an endoclipper, in which the type of ulcer defect is first determined by Jonhson and, with type 1 ulcer, clipping is performed on medium-sized vessels extending from the anterior and posterior descending branches of the left gastric artery, with type 2 ulcers, clipping they are carried out on the vessels feeding the posterior wall of the duodenum - branches of the anterior and posterior pancreatoduodenal arteries; with type 3 ulcers, clipping is performed on the branches of the right the arterial artery and branches of the upper and lower pancreas, while the clips are placed at a distance of 1.5-2.0 cm from the bleeding vessel (RU Patent Application No. 20100128665, publ. 01.20.2012, IPC A61B 17/00). The method is carried out during fibrogastroduodenography, that is, during inspection from the inside of the stomach and duodenum using special equipment - an endoclipator, and has a number of disadvantages.

There is a method of treating gastroduodenal bleeding from acute ulcers by ligation of the main arteries that feed the stomach and duodenum, depending on the location of the sources of bleeding with stitching the ulcer (Milonov O.B. Postoperative complications and dangers in abdominal surgery. / O.B. Milonov, K. .D. Toskin, V.V. Zhebrovsky. M.: Medicine, 1990.- P.234-235). The method allows to achieve reliable hemostasis in the ulcer. However, the ligation of the main arteries that feed the stomach and duodenum can lead to the development of extensive necrosis of the walls of these organs and peritonitis.

A known method of stopping bleeding from large arterial vessels of the bottom of a stomach ulcer and / or duodenum, in which duodenotomy is performed, a bleeding arterial vessel is identified at the bottom of the ulcer. To do this, the crater ulcers are released from liquid blood and clots with the help of an electric suction pump. With a clear visualization of the bleeding vessel, a coaxially small clamp of Kocher is placed on it, then traction is performed from the bottom of the ulcer of the intima of the vessel and it is ligated. Then, bleeding from large arterial vessels of the ulcer bottom is stopped, since only from them it is possible to stretch the intima of the vessel and bandage it. The disadvantage is that, firstly, it is necessary to perform a duodenotomy - this can threaten the inconsistency of the stitches in the postoperative period, and secondly, the method is applicable only to stop bleeding from large vessels and is not applicable to stop bleeding from small and medium-sized vessels, thirdly, the effect of acid secretion of the stomach in the postoperative period on the bottom of the ulcer can lead to arrosion of the bandaged vessel and repeated bleeding (RU No. 2445024, publ. 20.03.2012, IPC A61B 17/12).

The objective of the invention is to simplify the technique of surgical hemostasis for bleeding ulcers of the duodenum penetrating into the head of the pancreas, increase the efficiency of treatment of ulcerative bleeding in patients at increased risk, reduce the risk of recurrence of bleeding, reduce postoperative mortality.

The technical result is to stop bleeding from vessels of any caliber at the bottom of the penetrating ulcer without performing duodenotomy and suturing the ulcer by ligation of the vascular branches at the place of their departure from arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticioriorodiorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodiorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodioriorodiorodiorior

This is achieved by stopping bleeding from a duodenal ulcer penetrating into the head of the pancreas, in which, after endoscopic detection of a bleeding penetrating ulcer, laparotomy is performed and ligation around the ulcerative substrate of the vascular branches arteria pancreaticoduodenalis superior anterior, arteria pancreaticodiorodiodenodenoalodioododenoaldeno superior anodenoreatodenodenoaldeno superior anterior pancreaticoduodenalden superior superior, pancreic pancreaticoduorealdenal superior superior, anteria pancreaticoduodaldenal Superior superior, inferior posterior. In operations, the vascular branches of arteria pancreaticoduodenalis superior anterior and arteria pancreaticoduodenalis inferior anterior are first ligated. For ligation of the vascular branches of arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior, the duodenum is mobilized according to Kocher (Voylenko V.N. Atlas of operations on the abdominal wall and organs of the abdominal cavity. / V.N. Voilenko, A.I. Medelyan, V. M. Omelchenko. M.: Medicine. 1965. - 400 p., Fig. 349, Fig. 679, Fig. 678). Ligation of the vascular branches at the place of their departure from arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior leads to a stop of bleeding from vessels of any size. Hemostasis in an ulcer during surgery is controlled endoscopically. Ligation for surgery of vascular branches of arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior does not lead to circulatory disturbance in the intestinal wall because the posterior gland is missing, the posterior wall A sufficient number of vascular anastomoses is preserved for ulcers to ensure consistent blood circulation in the anterior wall of the duodenum.

Example 1

Patient M., 76 years old, was treated in the surgical department of the Republican Clinical Hospital No. 1 with a diagnosis of peptic ulcer of the duodenum, complicated by bleeding. Ischemic heart disease. Angina pectoris FC III. COPD Pulmonary heart failure 2 tbsp. He was in serious condition in the intensive care unit. Upon admission, an emergency fibrogastroduodenoscopy was performed, where it was found that the duodenal bulb is deformed by scars, and on the posterior-medial wall there is a deep ulcer of 0.8 × 0.6 cm in size, the bottom of which is filled with a red thrombus. Conclusion: Chronic penetrating duodenal ulcer complicated by bleeding. Unstable hemostasis. Cicatricial deformity of the duodenum. The patient underwent hemostatic therapy, transfusion of a single-unit erythrocyte mass and freshly frozen plasma. 4 hours after the diagnosis was established, a patient with a nasogastric tube appeared discharge with an admixture of red blood, the condition worsened sharply. With a diagnosis of relapse of bleeding from a duodenal ulcer, the patient urgently performed laparotomy. The lumen of the small and large intestines is filled with black masses of altered blood. Given the severity of the condition, the massiveness of blood loss, the presence of severe concomitant pathology, it was decided to perform the ligation of the vascular branches of the arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis superior posterior, and arteria pancreaticoduodenal superior pancreatic glandular inferior glandular inferior. Hemostasis in the ulcer during surgery was monitored endoscopically - the bottom of the ulcer is yellowish with small blood clots at the bottom, there are no signs of ongoing bleeding. In the postoperative period, the patient underwent hemostatic, antiulcer antisecretory, replacement therapy. With control fibrogastroduodenoscopy: a chronic duodenal ulcer without signs of bleeding. The bottom of the ulcer is covered with a grayish coating. Hemostasis is steady. Discharged in satisfactory condition.

Example 2

Patient M., 67 years old, was treated in the surgical department of the Republican Clinical Hospital No. 1 with a diagnosis of peptic ulcer of the duodenum, complicated by bleeding. Ischemic heart disease. Angina pectoris FC III. Postinfarction cardiosclerosis. Hypertension of the III stage, degree AH 3, Risk 4. Chronic obstructive bronchitis. Pulmonary heart failure II-III Art. Upon admission, an emergency fibrogastroduodenoscopy was performed, where it was found that there was fresh scarlet blood in the duodenal bulb, and there was a deep ulcer 1.0 × 0.8 cm on the posterior medial wall, the bottom was filled with a red clot, red blood was leaking from the edges of the ulcer. Conclusion: Chronic penetrating duodenal ulcer complicated by bleeding. Ongoing bleeding. The patient was urgently performed laparotomy. The lumen of the small and large intestines is filled with masses of altered dark-colored blood. Given the severity of the condition and the presence of severe concomitant pathology, the impossibility of a radical operation to resect the stomach, it was decided to perform a ligation of the vascular branches of arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticoduodenal superior pancreatic pancreatic pancreas . With intraoperative fibrogastroduodenoscopy, ongoing bleeding was not detected. In the postoperative period, the patient underwent hemostatic, antiulcer antisecretory, replacement therapy. In the control fibrogastroduodenoscopy, the ulcer is covered with a grayish coating to the level of the mucosa. Hemostasis is steady. Discharged in satisfactory condition.

In total, nine such operations were completed. All nine patients in the postoperative period recurrence of bleeding was not observed.

The claimed method allows to simplify the technique of surgical hemostasis with bleeding ulcers of the duodenum penetrating into the head of the pancreas, it allows to stop ongoing ulcerative bleeding without performing duodenotomy and suturing ulcers, to reduce the risk of bleeding recurrence, which is especially important in the treatment of elderly patients with a high risk of radical surgery, and also to prevent recurrence of ulcerative bleeding, reduce the number of postoperative complications and deaths. The ligation of the branches of arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior leads to a stop of bleeding from vessels of any caliber in the bottom of the penetrating ulcer. Compared with the known methods in the claimed method, the bleeding is stopped for a period without opening the lumen of the duodenum, not in an ulcer, therefore, there is no threat of vessel arrosion and repeated bleeding, the operation is less traumatic, there is no threat of the development of inconsistency of sutures on the wall of the duodenum. The claimed method of stopping bleeding can be the operation of choice in seriously ill patients with profuse hemorrhages from a duodenal ulcer, penetrating into the head of the pancreas.

Claims (1)

A method for stopping bleeding from a duodenal ulcer penetrating into the head of the pancreas, including the detection of a bleeding penetrating ulcer and ligation of an arterial vessel, characterized in that after endoscopic detection of a bleeding penetrating ulcer, laparotomy is performed and ligation is performed around the ulcerous substrate of the arterial eryteroodorodoideterodenoderdenuberoduardenoderdeterodenoderdenoderdenoderden inferior anterior, arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior.