RU2663388C2 - Method for anti-reflux pyloroplasty in pyloric sphincter dysfunction and schmieden syndrome - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to surgery and can be used for anti-reflux pyloroplasty in pyloric sphincter dysfunction and Schmieden syndrome. First circular incision is made from the lower edge of the pyloric sphincter along a lesser curve to the middle of the sphincter along a major curve, second incision is made from the middle of the sphincter along a lesser curve to the upper edge of the sphincter along a major curve, the third incision is made from the upper edge of the sphincter along a lesser curve to a high curve proximal to the sphincter by 1 cm, wherein the incisions pass through the sphincter, dissecting only the serous layer, and on the stomach – serous-muscular layers. Two rows of sutures are made, wherein the first row is seroserous circular seams, immersing the second circular incision, first and third circular incisions, invaginating a valve flap into the lumen of the stomach and pylorusare, sutured by the second row of nodal, serous-muscular sutures, wherein the upper fold of the valve flap along a lesser curve is smaller than the lower fold in a high curve.EFFECT: method allows preventing duodenogastric reflux.1 cl, 3 dwg

Description

The invention relates to medicine, namely to surgical gastroenterology, and can be used to restore the evacuation and closure function of the pyloric sphincter in the treatment of complicated forms of gastric ulcer and duodenal ulcer, cholelithiasis, postcholecystectomy syndrome, prevention of duodenogastric reflux, gastritis reflux syndrome .

Known methods of surgical treatment of pyloric sphincter insufficiency and Schmiden syndrome by performing pyloroplasty or combining it with other operations.

There is a method in which, in case of pyloric sphincter insufficiency after distal resection of 2/3 of the stomach, cholecystectomy, for the prevention of accelerated evacuation from the gastric stump, an operation option is used with circular immersion of the roller from the tissues around the perimeter of the applied gastroduodenoanastomosis or above the pylorus using serous-muscular sutures (A. G. Zemlyanoy et al., 1990. A method of treating dumping syndrome after resection according to the first Billroth method. // Vestn. Khir., 1990, 9, v. 145, p. 135-137).

There is a method of valvular pyloroduodenoplasty, in which the valve is formed by vertical immersion of the folds from its anterior wall into the lumen of the duodenum after resection of the stomach by Billroth - I (SF Alikperov. Valvular pyloroduodenoplasty in the treatment of complicated pyloroduodenal ulcers. Abstract. Cand. Diss. Honey. . Sciences, M., 1994).

The closest to the claimed solution is a method of pyloroplasty consisting in a rhomboid excision of the ulcer substrate on the anterior semicircle of the pyloric sphincter and performing transverse gastroduodenoplasty, characterized in that after excision of the ulcer substrate, the anterior semicircle of the pyloric sphincter is restored by suturing the wall of the stomach and the twelve intestinal fragments. sphincter at the upper and lower edges of the wound of the stomach, after which nvaginiruyut reconstructed front semicircle sphincter into the duodenum via provisory ligatures-derzhalok and tool-intestinal invaginator and form a pocket of the front wall of the duodenum sero-muscular sutures (patent №2215487, IPC A61V 17/00, publ. 2003).

Radiological and endoscopic studies on the closure function and incidence of reflux gastritis after known methods for correcting the function of the pylorus or pyloroduodenal transition showed that in patients all existing methods of pyloroplasty lead to the restoration of the evacuation function of the stomach. However, it should be noted that their common shortcomings are significant violations of the closure function of the pyloric sphincter and the development of reflux gastritis in 35-64.6% of patients. (V.I. Oskretkov et al., 1998. Lumber-cutting resection of the stomach in patients with chronic gastroduodenal ulcer. Collection of scientific papers of the All-Russian Scientific Conference "Actual Issues of Surgery" Rostov-on-Don, 1998, p. 210; G.A. Bulgakov, VA Kubyshkin, 2001. Current problems of surgical treatment of uncomplicated duodenal ulcer. Surgery, 2001, 5, p. 31-35). In addition, in the resulting pocket, stagnation of the gastric contents occurs with the development of inflammatory and erosive-ulcerative processes, relapse of Schmiden syndrome (slipping of the mucosa into the lumen of the pyloric canal).

The technical problem is to create a method of areflux pyloroplasty, providing a radical imparting an effective closure function to the pyloric sphincter, prevention of Schmiden syndrome and duodenogastric reflux.

The technical problem is achieved in that in the method of areflux pyloroplasty in case of pyloric sphincter insufficiency and Schmiden syndrome, including incisions and suturing on the walls of the stomach and duodenum, characterized in that the first circular section of the serous membrane is made from the lower edge of the pyloric sphincter along the lesser curvature to the middle sphincter of great curvature. The second section is from the middle of the sphincter along the lesser curvature to the upper edge of the sphincter along the greater curvature. The third section is from the upper edge of the sphincter along the lesser curvature to the greater curvature proximally at a distance of 1 cm from the sphincter. Incisions pass through the sphincter, dissecting only the serous membrane, and on the stomach, the serous-muscular layer. Then we put two rows of seams. The first row is gray-serous circular sutures, immersing the second circular incision. The first and third circular sections are sutured with a second row of nodular, serous-muscular sutures, which invaginate the valve flap formed in the lumen of the stomach and pylorus. The upper fold of the valve flap in lesser curvature is less than the lower fold in the greater curvature.

The technical result consists in the fact that the circular fold in the pyloric sphincter region gives it valve properties, prevents the pyloric canal from slipping off and prevents duodenogastric reflux.

The method is illustrated by the following drawings.

In FIG. 1 shows a diagram of three circular, oblique sections of the serous membrane of the pyloric sphincter and the stomach wall and a diagram of the application of the first row of serous sutures to the second section of the pyloric sphincter; in FIG. 2 shows a diagram of a second row of serous-muscular sutures placed on the front wall of the stomach and duodenum; in FIG. 3 shows a diagram of the upper smaller fold and the lower greater fold of the valve flap invaginated into the lumen of the pyloric stomach.

The diagram (Fig. 1) shows three circular, oblique incisions 1 of the serous membrane of the pyloric sphincter 2 and the anterior wall of the stomach 3, as well as the first row of serous sutures 4 to the second incision of the pyloric sphincter 2.

The diagram (Fig. 2) shows the second row of nodular sero-muscular sutures 5, superimposed on the front wall of the stomach 3 and duodenum 6.

The diagram (Fig. 3) shows the upper smaller fold 7, the second row of nodular sero-muscular sutures 5 and the lower large fold 8 of the valve flap, invaginated in the lumen of the pyloric stomach 3.

The method is as follows.

Perform digital and instrumental revision of the gastroduodenal junction. Its diameter should not be less than 2 cm. Then, along the lesser curvature of the stomach 3, the pyloric sphincter 2 region is mobilized while preserving the right gastric artery. The greater curvature of the stomach 3 also produce the mobilization of the sphincter 2 and part of the prepiloric stomach 3 with the preservation of the right gastro-omental gland. Three circular, oblique sections of the serous membrane of the pyloric sphincter and the anterior wall of the stomach are produced. In this case, the first circular section extends from the lower edge of the pyloric sphincter along the lesser curvature of the stomach to the middle of the sphincter along the greater curvature; the second section - from the middle of the sphincter along the lesser curvature of the stomach to the upper edge of the sphincter along the greater curvature of the stomach; the third section is from the upper edge of the sphincter along the lesser curvature to the greater curvature proximally at a distance of 1 cm from the sphincter. Incisions are made through the sphincter, dissecting only the serous, and on the stomach - the serous-muscular layers and impose two rows of sutures. The first row of gray-serous circular sutures, sutured the second incision in the sphincter. The second row of nodular, serous-muscular sutures is the first and third circular sections, invaginating the valve flap into the lumen of the stomach and pylorus, and the upper fold is smaller in curvature less than the lower fold in large curvature. Then ligatures are tied, with the help of which the first row of sutures is invaginated into the lumen of the duodenum and stomach. The circular fold in the area of the pyloric sphincter gives it valve properties, prevents the pyloric canal from slipping off and prevents duodenogastric reflux.

Thus, a circular fold is formed around the inner perimeter of the pyloric sphincter, which provides valve properties to the pyloric sphincter. With an increase in pressure in the intestine, the pyloric sphincter closes, with an increase in pressure in the stomach, it opens.

Case Study

Patient V., 46 years old. Was admitted to the clinic of faculty surgery at the Medical Institute of Oryol State University on March 26, 2002 with a diagnosis of Peptic ulcer, decompensated pyloric stenosis. Three years ago, she was operated on for chronic calculous cholecystitis in an open way. Gallstone disease suffers for 10 years. 1 year after the operation, pain in the epigastric region, vomiting after eating began to disturb. She was treated by a local therapist with a diagnosis of duodenal ulcer (duodenal ulcer), postcholecystectomy syndrome. In the last 6 months, the patient's condition worsened: the pain began to be permanent, vomiting became more frequent, the patient lost 8 kg. After emptying and washing the stomach with a probe, an esophagogastroduodenoscopy (EFGDS) was performed. When EFGDS detected mucosal edema, more pronounced in the antrum, pinpoint hemorrhages on the mucosa, surrounded by pyloric pulp. It was not possible to hold the end of the probe for the pylorus into the bulb of the KDP. A fluoroscopy of the stomach was done. The barium solution remains in the stomach. When repeated x-ray after 24 hours - most of the solution of barium in the stomach and traces of barium in the small intestine. After preoperative preparation of the patient, an operation was performed on March 30, 2002. Verkhnesomedinaya laparotomy. Dissection of adhesions in the subhepatic space and viscerolysis of the upper horizontal part of the duodenum. In the area of the pyloric pulp, a rounded elastic formation was found that did not pass the index finger from the stomach. With tension of the anterior wall of the stomach and compression with a finger from the side of the duodenal bulb, the formation in the pyloric area easily straightened, and the finger began to easily pass through the pyloric canal into the cavity of the stomach. Through the stomach, a gastric tube is installed in the duodenum. The pylorus area has been mobilized from the side of small and large curvature. In the area of the pylorus and the wall of the stomach, three circular oblique incisions were made along the great curvature without damage to the muscle fibers of the sphincter and mucous membrane. The first row of gray-serous circular sutures was laid, then the second row of nodular serous-muscular sutures. Nasoduodenal intubation with a polyvinyl chloride probe was performed. The abdominal cavity is drained through the right hypochondrium. The postoperative period was uneventful. 04/11/2002 was discharged in satisfactory condition. September 21, 2002 was produced by EFGDS. There are no data for duodenogastric reflux and reflux gastritis, the pyloric sphincter is hyperemic, 15 mm in diameter. 09/22/2002, an X-ray examination of the stomach and duodenum was performed. The stomach is of normal size. There is an X-ray picture of the usual pyloric sphincter, there is no duodenogastric reflux, portioned evacuation of the contrast mass from the stomach within 1 hour 40 minutes is noted. Endoscopic and radiological examinations 1 year after surgery did not give data for narrowing or insufficiency of the pyloric sphincter. Its good motor and evacuation function was discovered.

This method of operation was used in 14 patients. The increase in time of the main operation was 30-40 minutes.

Claims (1)

The method of areflux pyloroplasty in case of pyloric sphincter insufficiency and Schmiden syndrome, including incisions and suturing on the walls of the stomach and duodenum, characterized in that the first circular incision is made from the lower edge of the pyloric sphincter along the lesser curvature to the middle of the sphincter along the greater curvature, the second section is carried out from the middle of the sphincter along the lesser curvature to the upper edge of the sphincter along the greater curvature, the third section is carried out from the upper edge of the sphincter along the lesser curvature to the greater curvature 1 cm from the sphincter, the incisions passing through the sphincter, dissecting only the serous, and the serous-muscular layers on the stomach, after which two rows of sutures are applied, with the gray serous circular sutures immersing the second circular incision being the first row, and the second the first and third circular sections are sutured along with a series of nodular, serous-muscular sutures, invaginating the valve flap formed in the lumen of the stomach and pylorus, and the upper fold of the valve flap along the small curvature is less than the lower fold along the large cree vise.

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