RU2706143C1 - Method for surgical treatment of penetrating duodenum ulcers complicated by bleeding - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for surgical treatment of penetrating ulcers of duodenum complicated by bleeding, with tissue deficiency. Upper-middle laparotomy is performed. Duodenum is inspected, further mobilization of stomach and duodenum. Posterior wall of the duodenum is excised around the ulcer. Bleeding vessel is stitched. Edges of the duodenal wound are adapted by superimposing serous-submucosal sutures. Duodenal wound is covered with a gastric flap, which is cut out of the greater curvature of the stomach on the vascular pedicle.

EFFECT: method enables visualizing the ulcer during the intervention, reducing the risk of necrotic processes.

1 cl, 2 dwg

Description

The invention relates to medicine, namely surgery, and can be used in the surgical treatment of penetrating duodenal ulcers complicated by bleeding.

Surgical treatment of penetrating ulcers complicated by bleeding is the most difficult type of surgical intervention on the duodenum, since the penetrating ulcer not only completely destroys the posterior wall of the duodenum, but also always lies in the area of the anatomically close location of the affected duodenal wall to the pancreas and large blood vessel bile duct, which are intimately involved in the area of paralyzed infiltrate by inflammatory, scarring soldering process and form a bottom directly penetrating ulcers.

Known methods for surgical treatment of penetrating duodenal ulcers, which consists in cutting off the posterior duodenal ulcer from the edges of the penetrating ulcer ("extraduodenization" of the duodenal ulcer), followed by removal of the affected segment of the duodenal ulcer or its plastic restoration A. Redeoplastan A. (duo. and transperitoneal extirpation of the stomach ". Leningrad, Medgiz, 1961, p. 38-42, 129-138. I.N. Navrotsky." Suturing the stump of the duodenum. "M .: Medicine, 1972. S. S. Yudin." Etu gastric surgery ". M: Medicine, 1965, pp. 99-104. V. Onopriev." Studies in functional surgical gastroenterology ", Krasnodar, 1995). The main disadvantages of these methods are:

- high probability of pancreatic tissue damage;

- the risk of damage to large arterial and venous vessels;

- the likelihood of trauma to the common bile and pancreatic ducts.

Known methods of surgical treatment that offer to perform surgery outside the "danger zone" with the penetrating ulcer in the lumen of the duodenum by crossing the duodenum or distal stomach above the localization of the penetrating ulcer with subsequent suturing and resection of 2/3 of the stomach Billroth-2 in order to stop the passage of acidic gastric contents through the duodenum and create favorable conditions for self-healing of ulcers (resection turn-off tree according to Finsterer (1918), Pauchet (1925), Devine (1928), S. S. Yudin (1951), Heinatsu (1955) and others) (A. A. Rusanov. "Resection and peritoneal extirpation stomach. "Leningrad, Medgiz, 1961, p. 38-42, 129-138. S. S. Yudin." Etudes of gastric surgery ". M: Medicine, 1965, p. 99-104. I.N. Navrotsky. "Suturing the stump of the duodenum." M: Medicine, 1972). The disadvantages of this method are:

- the need for gastric resection "on off";

- frequent occurrence of profuse ulcerative bleeding in the early postoperative period from the left ulcers.

A known method of surgical treatment of peptic ulcer of the duodenum by excision of the ulcer, followed by suturing of the edges of the defect (VI Onopriev. Segmented duodenoplasty with selective proximal vagotomy. Copyright certificate 971286, 1980). The method involves transverse dissection of the anterior wall of the duodenum, mobilization of the posterior wall, excision of pathologically altered tissues, release of the suprabulbar and pyloric portions along the posterior wall, smoothing the wall of the pseudo-diverticulum from the mucosa, restoration of the ampoule of the duodenum, followed by stitching of the dissected edges of the defect. The disadvantage of this method:

- refers to the complete transverse intersection of the duodenum and interruption of intraduodenal vascular and nerve connections;

- violation of the motor-evacuation functions of the duodenum;

- the need to perform duodenotomy.

- the likelihood of developing cicatricial stenosis of the duodenum.

There is a method in which in order to avoid damage to the pancreas, large blood vessels, common bile duct and stopping bleeding, an ulcer is left in the lumen of the duodenum, performing only duodenotomy and stitching of penetrating ulcer with interrupted sutures (AF Chernousov et al. "Surgery of peptic ulcer stomach and duodenum ". M: Medicine, 1996, S. 94-99).

The disadvantage of this method includes:

- leaving an ulcer in the lumen of the duodenum;

- a high probability of recurrence of bleeding from an ulcer left in the lumen of the duodenum;

- the need to perform duodenotomy. The closest way to the proposed one is the method of surgical treatment of penetrating duodenal ulcers complicated by bleeding Anatoly Nikandrovich Volkov et al., Patent No. 2510245 dated 03.03.2014, including the detection of a bleeding penetrating ulcer and ligation of an arterial vessel, characterized in that after endoscopic detection of bleeding penetrating ulcers perform upper-median laparotomy, mobilization of the duodenum according to Kocher, and carry out ligation around the ulcer substrate udist branches of arteria pancreaticoduodenalis superior anterior, arteria pancreaticoduodenalis inferior anterior, arteria pancreaticoduodenalis superior posterior, arteria pancreaticoduodenalis inferior posterior.

However, this method has its drawbacks:

- leaving a peptic ulcer of the posterior wall of the duodenum;

- ligation of large vessels can lead to necrotic processes in the wall of the duodenum and the head of the pancreas;

- high risk of perforation of the duodenal ulcer;

- high probability of damage and ligation of the pancreatic ducts;

- lack of visualization of the ulcer and the need to use a fibroesophagogastroduodenoscope during surgery.

The alleged invention is aimed at improving the results of surgical treatment of patients with penetrating duodenal ulcers complicated by bleeding.

The specified technical result is achieved by dissecting the posterior wall of the duodenum around the ulcer, suturing the bleeding vessel, adapting the edges of the duodenal wound by applying serous-submucosal sutures, and in case of tissue deficiency, the duodenal wound is covered with a full-layer gastric flap that is cut out of the stomach with a curvature of the knife , and then the wound is sutured in layers.

The proposed method for the surgical treatment of penetrating duodenal ulcers complicated by bleeding, in addition to stopping bleeding and reconstruction of the duodenum, provides for the restoration of full motor-evacuation function of the stomach and duodenum. This method can be used for penetrating bleeding ulcers of the duodenum. With low located ulcers of the duodenum, this technique is not shown.

The essence of the invention is illustrated by drawings, where:

- FIG. 1 - excision of the posterior wall of the duodenum around the ulcer and flashing of a bleeding vessel.

- FIG. 2 - covering the defect of the posterior wall of the duodenum with a full-layer gastric flap on the vascular pedicle, which emerges from the greater curvature of the stomach.

The proposed method was successfully tested in the surgical department of GBUZ JSC GKB No. 3 in 7 patients for the period. Below are the results of testing.

Example 1

Patient P., 48 years old, was admitted to the surgical department of the City Clinical Hospital No. 3 12/15/2017, with a diagnosis of Duodenal ulcer. Gastrointestinal bleeding F-2A.

Ulcerative history for 5 years. The day before, I felt weak, dizzy, fainting, had black stools, and therefore was hospitalized in the hospital on duty. From the admission department, the patient is directed to fibroesophagogastroduodenoscopy (FEGDS). On FEGDS: on the posterior wall of the duodenal bulb there is a flat, fixed dark thrombus up to 0.6 cm in diameter, from under which a fragment of a ulcerative defect is visible.

The patient was hospitalized in the intensive care unit, where hemostatic, infusion, antiulcer therapy was carried out.

12/16/2017, Relapse of bleeding. The patient was taken to the operating room. Under endotracheal anesthesia, the upper median laparotomy was performed. During the audit, pronounced perigastritis, periduodenitis. Mobilization of the stomach and duodenum. An ulcer of the posterior wall of the duodenum was found, penetrating into the head of the pancreas. The posterior wall of the duodenum was excised around the ulcer, the bleeding vessel was stitched, and serous-submucosal sutures were placed on the edges of the duodenal wound. Layered stitches on the wound.

The postoperative period was uneventful. On the 12th day after the operation, the patient was discharged in satisfactory condition for outpatient treatment.

Example 2

Patient G., 55 years old, was hospitalized on an emergency basis on January 19, 2018 to the surgical department with a diagnosis of Duodenal ulcer. Unstable bleeding F-2A. Ulcerative history of 7 years. At admission: the patient's condition is moderate. The skin and visible mucous membranes are pale pink. Pulse - 98 beats / min, blood pressure - 110/70 mm RT. Art. When examining the rectum, black feces are on the glove. Blood tests: hemoglobin - 93 g / l, er - 3.1 × 1012 / l, white blood cells 9.0 × 109 / l.

Completed by FEGDS: we pass the esophagus, the cardia socket does not close tightly. The stomach contains a small amount of hematin and dark clots. Mucous with hematin smears, its folds are low, longitudinally crimped. The gatekeeper is round, gaping. The duodenal bulb of the usual form on the back wall at the border with the pylorus has an ulcer of 0.7 × 0.8 × 0.1 cm, in the bottom there is a flat fixed thrombus from which blood leaks out. Given the ongoing bleeding, the patient is shown emergency surgery.

Under endotracheal anesthesia, the upper median laparotomy was performed. During the audit, a penetrating duodenal ulcer was found in the head of the pancreas. From the large curvature of the stomach, a full-layer flap of the stomach was cut out on the right gastro-omental gland, with closure of the gastric defect in the longitudinal direction with a 2-row interrupted suture. An excision of the posterior wall of the duodenum around the ulcer was made, and bleeding was stopped by flashing a bleeding vessel. The resulting defect in the area of the posterior wall of the duodenum is covered with a previously cut gastric flap. Layered stitches on the wound.

The postoperative period was uneventful. On the 14th day after the operation, the patient was discharged in satisfactory condition for outpatient treatment.

Example 3

Patient P., 39 years old, was admitted to the surgical department of the City Clinical Hospital No. 3 on February 16, 2018 with a diagnosis of Duodenal ulcer. Gastrointestinal bleeding F-2A.

Peptic history for 5 years. The day before I felt weak, dizzy, had black stools, and therefore was hospitalized in the on-call hospital. In the ward, the patient underwent fibroesophagogastroduodenoscopy (FEGDS).

On FEGDS: on the posterior wall of the duodenal bulb there is a flat, fixed dark thrombus up to 0.8 cm in diameter, around which a fragment of a peptic ulcer is visible.

The patient was hospitalized in the intensive care unit, where hemostatic, infusion, antiulcer therapy was carried out. 02.17.2018. Relapse of bleeding. The patient was taken to the operating room. Under endotracheal anesthesia, the upper median laparotomy was performed. During the audit, an ulcer of the posterior wall of the duodenum was found penetrating into the head of the pancreas. Mobilization of the stomach and duodenum. The posterior wall of the duodenum was excised around the ulcer, the bleeding vessel was stitched, and serous-submucosal sutures were placed on the edges of the duodenal wound. Layered stitches on the wound.

The postoperative period was uneventful. On the 13th day after the operation, the patient was discharged in satisfactory condition for outpatient treatment.

The proposed method improves the results of surgical treatment of patients with penetrating duodenal ulcers complicated by bleeding, namely:

- reliable hemostasis of a bleeding ulcer;

- reduction of trauma to organs involved in the pathological process (without gastro and duodenotomy);

- restoration of the full motor-evacuation function of the stomach and duodenum;

- eliminates the effect of an aggressive acidic environment on the ulcer.

These features of the method are conditions that improve the results of surgical treatment of patients with penetrating duodenal ulcers complicated by bleeding, helping to reduce the risk of postoperative complications, improving the quality of life of patients.

The developed method can be widely used in the practical work of surgical departments.

Claims (1)

A method of surgical treatment of penetrating duodenal ulcers, complicated by bleeding, with tissue deficiency, including flashing of a bleeding vessel, characterized in that the upper-median laparotomy is performed, the duodenum is revised, the stomach and duodenum are mobilized further, the anterior duodenum is excised, suture the bleeding vessel, adapt the edges of the duodenal wound by applying serous-submucosal sutures, cover the duodenal wound with the gastric lobe a scoot, which is cut out from the great curvature of the stomach on the vascular pedicle, then the wound is sutured in layers.

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