RU2614884C1 - Method for preventing inconsistency of "difficult" duodenal stump - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: invention relates to medicine, surgery. In the process of stomach resection extensive mobilisation of anterior-lateral wall of duodenum is performed. Posterior-medial wall is exposed in limited way below ulcer to 5 mm. Duodenal stump is sewn with one-row suture. Transverse gastroduodenoanastomosis with anterior duodenal wall is formed with 1.5-2 cm indent from the edge of sewn stump.

EFFECT: method makes it possible to include duodenum into digestion, provides prevention of inconsistency of gastroduodenal anastomosis with "difficult" duodenal stump in case of low complicated duodenal ulcers due to decompression of duodenum (waterfall phenomenon) and application of anterior wall of duodenum for gastroduodenal anastomosis.

1 ex, 2 dwg

Description

The invention relates to medicine, namely to surgery, can be used to prevent insolvency of the duodenal stump with low complicated duodenal ulcers.

Analogs

Suturing the stump of the duodenum is one of the main and critical stages of gastric resection. The failure of the seams of the “difficult” duodenal stump (duodenum) is one of the formidable complications after resection of the stomach, the frequency of which reaches 10-20% (Chernousov A.F., 1985; Nikitin N.A., 2001; B. Lannois et al. , 1986). Mortality in the development of insolvency of the suture of the duodenal stump in the early postoperative period is 25-70% (Zemlyanoy A.G., Aliev S.A., 1985; Bogdanov A.V., 2001, Rukhlyada M.V. et al., 2006) .

The main risk factors and criteria for the development of inconsistency of the joints of the “difficult stump” of the duodenum after stomach resection are: low-lying complicated duodenal ulcers, postoperative pancreatitis due to pancreatic injury, lack of plastic material and the absence of reliable atypical methods for suturing the stump, increased intraluminal pressure in the duodenal stump with duodenal stump with bile and pancreatic juice, chronic duodenal obstruction. With the removal of a low complicated onion, postbulbar ulcer, the incidence of insolvency reaches 23.5% (Vinichenko A.G., 1982), and in the presence of deep penetration, the frequency increases to 87.5% (Onopriev V.I., 1995, Shepetko E.N. ., 2012).

In complicated pyloroduodenal ulcers, when organ-preserving operations are technically impossible, the second Billroth method is most common and forced to be performed, while stomach resection by Billroth I is recognized by many authors as the most convenient and functionally beneficial (Zherlov G.K., 2001, Zaitsev O.V. . et al., 2011).

There is a known method for the prevention of duodenal insufficiency by atypical suturing of the stump, followed by covering with a capsule of the pancreas, a flap of the greater or lesser omentum and performing gastrectomy by Billroth II to turn off the duodenum from food transit.

One of the main reasons for the failure of sutures during atypical closures of the duodenal stump is trauma to the pancreas, unreliable tight closure of the “difficult stump” in the tissue infiltration zone against the background of high intraluminal pressure in the duodenum, which contributes to the development of acute postoperative pancreatitis (Rozanov IB, Stonogin V .D., 2013).

Disadvantages:

1. Increase in intraluminal pressure in the duodenum with teething.

2. With a "low" treatment of the duodenal stump, it is not possible to form a reliable second row of sutures with the capture of fibro-altered tissues, which leads to failure of the sutures.

3. The development of acute pancreatitis, pancreatic necrosis in the postoperative period.

4. Turning off the duodenum from digestive transit.

Known methods for the prevention of duodenal insufficiency are: Balfour gastric resection and pendant end, lateral compression by Pezzer's catheter duodenostomy according to Kanshin NN, 2004; Liszka, 1965.

Disadvantages:

1. Large loss of bile and pancreatic secretion through a duodenostomy fistula.

2. The formation of a long-functioning fistula in the postoperative period.

3. Long term hospitalization.

4. The need for reoperation in order to close the fistula.

5. Turning off the duodenum from digestive transit.

6. Additional internal drainage of the proximal segment of the small intestine during Balfour gastric resection does not always prevent the failure of the suture of the duodenal stump, because motor-evacuation disorders of the duodenum remain.

The prototype of the proposed method is the method of Billroth I for the prevention of insolvency of the "difficult" stump of the duodenum, completion of the resection stage of the operation by highlighting the scar-modified posterior wall of the duodenum after removal of the drug over 5 mm and the formation of a single-row end-to-end gastroduodenoanastomosis, proposed by A.G. Zemlyanoy in 1985 (Zemlyanoy A.G., Aliyev S.A. Prophylaxis of insolvency of sutures of the duodenal stump during resection of the stomach for pyloroduodenal ulcers. Herald of surgery, 1985; 134 (4). - P. 26-31).

This method has its drawbacks, which can lead to postoperative complications in both the early and late postoperative period:

1. The formation of a single-row suture of the anastomosis with a fibro-altered wall is unreliable and can lead to the development of gastroduodenoanastomosis insolvency in the early postoperative period.

2. "Low" allocation of the posterior wall of the duodenum for the formation of anastomosis leads to trauma to the pancreas with the development of pancreatitis in the postoperative period.

3. The formation of the end-end gastroduodenal anastomosis with the capture of fibrous tissue into the anastomosis leads in the long term to the development of cicatricial stricture of the anastomosis with evacuation disorders of the digestive tract.

The aim of the invention was to ensure the reliability and feasibility of gastroduodenoanastomosis in case of a “difficult” ulcer, i.e. turn the treatment of the “difficult stump” of the duodenum from the noli me tangure organ into the object of the surgeon’s usual activities.

This goal is achieved by the hybrid technology of the first and second Billroth methods. The resection stage ends with preliminary suturing of the “difficult stump” with a single-row suture in combination with a draining transverse gastroduodenostomy, which avoids the extensive mobilization of the posterior wall of the duodenum with the prevention of increased pressure in the duodenal stump, i.e. "Anastomosis is stronger than a stump."

Thus, the achievement of good immediate and long-term results is achieved by decompression of the duodenum (waterfall phenomenon) by drainage and gastric stump, which prevents an increase in intraluminal pressure and the failure of the joints of the “difficult stump” of the duodenum in the early postoperative period. The use of the anterior wall of the duodenum for gastroduodenal anastomosis allows the anastomosis to be reliably formed and the duodenum to be included in the digestive tract.

SUMMARY OF THE INVENTION

The essence of the proposed method is illustrated in FIG. 1 and FIG. 2, where pos. 1 - esophagus; pos. 2 - a stump of the resected stomach; pos. 3 - a seam on the cult of the duodenum; pos. 4 - transverse gastroduodenoanastomosis with the front wall of the duodenum; pos. 5 - KDP.

The proposed method for the prevention of insolvency of the "difficult" stump of the duodenum is as follows.

During resection of the stomach, a wide mobilization of the anterior lateral wall of the duodenum is performed with its release from under numerous adhesions, but by limiting the allocation of the posterior, posterior medial wall below the ulcer to 5 mm in order to avoid the development of post-traumatic pancreatitis. A strip of 5 mm wide along the back wall is sufficient for suturing the stump (Fig. 1, item 2) with a single-row suture or for a hardware suture at the level of stenosis, followed by the formation of a transverse gastroduodenoanastomosis with the anterior wall of the duodenum, 15 mm from the edge of the stitched duodenal stump.

Preservation of gastroduodenal transit with the formation of a reliable anastomosis is combined with decompression of the “difficult stump” of the duodenum, the absence of wide mobilization of the posterior wall of the duodenum, less traumatic pancreas, and the prevention of early postoperative complications.

Comparative analysis of the features of the prototype and the present invention

Signs of the prototype:

- the formation of an unreliable single-row suture of the anastomosis with fibro-altered wall;

- skeletonization of the pancreas with the allocation of the posterior wall of the duodenum;

- a high percentage of cicatricial stricture of the gastroduodenal anastomosis in the long-term postoperative period.

Features of the invention:

- the formation of a reliable anastomosis with an unchanged front wall of the duodenum;

- the absence of the need to highlight the posterior wall of the duodenum and traumatic damage to the pancreas;

- the formation of a wide transverse gastroduodenal anastomosis significantly reduces the risk of developing scar stricture in the long-term postoperative period.

An example of a specific implementation of the method

In the thoraco-abdominal department of the GBU RD "Scientific and Clinical Department" Dagestan Center for Thoracic Surgery ", a method for preventing insolvency of the" difficult "duodenal stump during gastric resection was used in 18 patients. The results of surgical interventions were evaluated by clinical observation in the postoperative period, radiological and endoscopic research methods.

Patient Y., 56 years old, was operated on with a clinical diagnosis: Giant antrum stomach ulcer, complicated by deep penetration into the pancreas, hepatoduodenal ligament, in combination with a low postbulbar duodenal ulcer.

Operation protocol

Subtotal resection of the stomach in combination with low treatment of the duodenal stump and the formation of transverse gastroduodenoanastomosis. Abdominal drainage.

Under general anesthesia, an upper median laparotomy was performed. During the audit: in the antrum, a giant ulcer 6 cm in diameter with deep penetration into the pancreas, into the hepatoduodenal ligament, accompanied by a pronounced cicatricial process; in particular, the gatekeeper does not differentiate. The stomach is subtotally mobilized with a large and small omentum and with externalization of an ulcer from the lumen of the stomach; at the same time, the presence of a second penetrating postbulbar duodenal ulcer into the pancreas was established. Mobilization of the duodenum according to Kocher with an ulcer. Treatment of the duodenal stump after separate removal of the second penetrating (at d = 2 cm) ulcer was difficult due to duodenal infiltration with displacement of the excretory bile and pancreatic ducts. The treatment of the “difficult” stump with a single-row nodal suture is supplemented with a wide transverse gastroduodenoanastomosis according to the developed technique. Control for hemostasis. The operation is completed by drainage of the right side channel. Stitches on the abdominal wall.

The postoperative period was uneventful. The wound healed by primary intention. Histological conclusion: chronic gastric ulcer.

A comparative analysis of the results of clinical observations showed the following.

The clinical application of the method for the prevention of insolvency of the "difficult" duodenal stump in gastric resection due to the extensive, low located ulcerative process in 11 patients showed the advantage of the developed intervention. There is no insolvency of the transverse gastroduodenal anastomosis and insolvency of the sutured “difficult” duodenal stump in the early postoperative period. The lack of insolvency was confirmed by x-ray and endoscopic examinations. Patients in the long-term postoperative period were examined in dynamics after 3, 6 and 12 months. Signs of cicatricial stenosis of the transverse gastroduodenoanastomosis were also not noted. In 1 patient, a picture of catarrhal anastomositis was observed at the follow-up period after 3 months, which was stopped by conservative measures.

The postoperative period of the patient A. Yagibekov, 56 years old, proceeded smoothly, without complications. On the 4th day, the nasogastric tube was removed; on the 5th day, enteral nutrition was established. During the control X-ray examination, the gastroduodenal anastomosis is freely passable, the evacuation of barium suspension into the duodenum is free, timely, there are no signs of contrast stains. The patient was discharged on the 10th day after surgery in a satisfactory condition.

The positive effect of the application of the invention

A method for the prevention of insolvency of the "difficult" stump of duodenum with gastric resection was tested in 11 patients in the thoraco-abdominal department of the Scientific and Clinical Department "Dagestan Center for Thoracic Surgery".

Functionally beneficial surgical interventions have become increasingly widespread in surgical gastroenterology. The functional benefits of maintaining duodenal passage have been proven by numerous studies. Therefore, the search and improvement of technology for the implementation of more functionally advantageous operations continues.

A method for the prevention of insolvency of a “difficult” duodenal stump during gastric resection can reliably prevent the development of insolvency of the sutured duodenal stump in the early postoperative period. The formation of a transverse gastroduodenal anastomosis allows the inclusion of duodenum in the food passage, which undoubtedly has functional advantages over reconstruction with the “duodenal ulcer” shutdown (Billroth II in various modifications).

The use of the developed method for the prevention of insolvency of the "difficult stump" of the duodenum allows in the long term to prevent the development of cicatricial strictures with evacuation disorders from the stomach stump. The proposed method for the prevention of insolvency of the "difficult stump" of the duodenum can be used in abdominal surgery as a reconstructive stage after resection of the stomach due to "low" complicated bulbous ulcers, significantly reduces the risk of scar stricture in the long-term postoperative period.

Information sources

1. Suturing the stump of the duodenum. I.N. Navrotsky, 1972.- 183 p.

2. Zemlyanoy A.G., Aliev S.A. Prevention of failure of sutures of the stump of the duodenum during gastrectomy for pyloroduodenal ulcers. Herald of Surgery, 1985; 134 (4). - S. 26-31. - The prototype.

3. Sheletko E.N. Surgical treatment of complicated papillary ulcers, 2012. - 198 p.

4. Onopriev V.I. Etudes of functional surgery of peptic ulcer, Krasnodar.

Claims (1)

A method for the prevention of insolvency of the “difficult” duodenal stump, which consists in the fact that, when the stomach is resected, a wide mobilization of the anterior lateral duodenal wall is performed with limited posterior medial wall below the ulcer up to 5 mm, the duodenal stump is sutured with a single-row suture and then transverse gastroduodenoanastomosis is formed with the front wall of the duodenum, retreating 1.5-2 cm from the edge of the sutured stump.

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