SU1657160A1 - Post-bulbar surgery of duodenal ulcer - Google Patents

Abstract

This invention relates to surgery, in particular to the surgical treatment of complicated duodenal ulcers. The aim of the invention is to restore the outflow of bile and pancreatic secretion in the surgical treatment of post-bulbar sores with simultaneous damage to the distal choledochus. A segmental resection of the duodenum and a longitudinal dissection of the choledoch narrowed area were performed. The choledoch is sewn into the posterior wall of the duodenum in the area of duodeno-anastomosis. 2 Il.

Description

This invention relates to surgery, in particular to the surgical treatment of complicated duodenal ulcers.

The aim of the invention is the restoration of the outflow of bile and pancreatic secretion with lesions of the distal choledochus by suture, and ligation of the common bile duct into the duodenoanastomosis.

Figure 1 shows the lesion after duodenotomy; Fig. 2 shows the formed lip of the anastomosis.

In Figures 1 and 2, the following are indicated: stomach 1, duodenum 2, choledoch 3. Zva 4 and Vater papilla 5.

The method is carried out as follows.

Upper median laparotomy is performed. The liver is shifted to the right. Examine the stomach, duodenum, liver, gall bladder, hepatoduodenal ligament, palpation examines the pancreas. The presence of ulcerative infiltration, adhesions periprocess, duodenal deformity confirms the ulcer disease. An increase in the size of the gallbladder, its overflow with bile with difficult emptying during compression, an increase in the diameter of the supra-duodenal choledochus indicate the presence of hypertension in the biliary tract due to the stenosis of the distal choledochus. Up to 200.0 ml of a 0.25% novocaine solution is administered under the duodenum and around the head of the pancreas. The duodenum is mobilized by Kocher. They remove all cicatricial overlaps covering the intestine in the zone of ulcers. At the same time, the hepatoduodenal ligament is additionally exposed, which makes it possible to more thoroughly assess the size of the choledochus. The localization of ulcers (intestinal wall, intestinal section), the degree of stenosis are approximately determined. the presence of pseudodivertikules, the state of the pyloric pulp. Mobilization of the side walls of the intestine at the level of ulcers with the near-wall doping of vessels is carried out. At the level of palpatorno determine

WITH

about

SP v |

oh oh

In the presence of an ulcer or ulcer infiltrate, or in the presence of stenosis of 3–5 mm distal, the anterior and partially lateral duodeno- toomy of the anterior wall is performed and an additional revision of the duodenum and the distal biliary tract is performed visually and by palpation through the lumen guts. At the same time, the localization of ulcers 4, its dimensions, the presence and depth of penetration, and the organ, where the ulcer penetrates, the relation of ulcers to the pyloric pulp of the stomach 1 and the condition of the latter, the severity of stenosis and pseudodivercules, are specified. The ratio of the ulcer to the Vater papilla 5, the distal section of the choledochus 3 and their changes is evaluated. The causes of bile outflow disturbance are determined (cicatricial structure of the Vater papilla or the distal choledochus, compression of the distal choledochus by the Cicatricial tissues or ulcerative infiltrate). Attention is drawn to the possibility of the presence of the choledochoduodenal fistula, its size, the distance from the Vater papilla 5, the relationship with the star 4. The biliary tract is verified by compressing the gall bladder, probing the Vater papilla or the fistula, estimate the intensity of pancreatic juice release. Then, excision of the intestinal wall 2 affected by the step process is performed. Excision is performed either with leaving the bridge unchanged walls of the posterior or posterior-lateral walls, or with complete intersection of the intestine 2 and resection of its segment. Ulcer 4 is excised completely or, if penetrated, its bottom is left on the underlying tissues. The rear walls of the proximal and distal ends of the crossed intestine under close visual inspection mobilize: distal within 3-5 mm, proximal until it penetrates the cavity of the lesser omentum. The distal part of the choledochus 3 is freed from the surrounding and compressing Cicatricial tissues. If at the same time its lumen is not restored, one can think about its cicatricial transformation, a longitudinal dissection of its front wall is performed in the zone of constriction from the mouth of the Vater papilla 5 over 1.5 cm or to the level of its expansion. If the level of stenosis is located above the Vater papilla, then its permeability is controlled (for sufficient outflow of pancreatic secretion), and the anterior wall of the common bile duct 3 is dissected outside the Vater papilla 5 at the contraction level also up to 1.5 cm . After that, the lower edge of the chopped anterior wall of the common bile duct is stitched with 4-6 sutures with the posterior wall of the distal end of the crossed intestine, and the upper edge with the posterior wall of the proximal end (Fig. 2). After this, the proximal and distal ends of the crossed intestine 2 are stitched end-to-end medially and laterally formed by the choledochoduodenal fistula (figure 2). In this way, surgery is performed on segmental duodenoplasty. In the duodenoplasty bridging method, the imposition of the choledochoduodenal fistula is identical, but when the duodenoduodenal anastomosis is performed, a portion of the preserved bridge of the intestinal wall is excluded from the suture line.

Example. Patient A., 41 years old. Diagnosis: duodenal ulcer, subcompensated stenosis, peteral ulcer with choledochoduodenal fistula. The peptic ulcer suffers over 10 years, the disease is progressive, there were repeatedly ulcer bleeding. The pain was localized in the epigastrium and right hypochondrium. The indication for surgery was subcompensation of stenosis.

With fibrogastroduodenoscopy, the deformity of the bulb, stenosis of the output section of the bulb with the presence of a deep ulcer at the level of stenosis were detected. It was not possible to inspect in detail the sound and post-bulbar section due to the presence of stenosis, which does not transmit the apparatus.

The operation revealed stenosis of the output section of the bulb with an internal diameter of about 6 mm, here. on the posterior wall, the calvarium penetrated the hepatoduodenal ligament, at the bottom of which the choledochoduodenal fistula was located. The mouth of the Vater papilla was opened 10 mm distal, the terminal part of the choledochus was involved in the ulcerative infiltrate and stenosed by it. The features of the ulcer, the presence of a fistula were established after transverse duodenotomy of the anterior wall at the ulcer level. Produced segmental excision of the walls of the duodenum in the ulcers with the preservation of the pyloric sphincter. Choledoch from the mouth of the papilla through the fistula and proximal 5 - 6 mm longitudinally dissected. When a duodenoduodenal anastomosis is applied end-to-end, the dissected choledoch is sewn into the duodenal wall along the duodenoplasty line. Imposed unloading cholecystostomy. The postoperative course is smooth.

Selective proximal vagotomy was performed by the second stage.

Control examination after 5 years. The patient is completely healthy, has no complaints. Over the past years, there have been no clinical manifestations of pathology on the part of the stomach, duodenum, biliary tract and pancreas.

The results of instrumental studies.

Fibrogastroduodenoscopy. Esophagus and cardi without features. The stomach of the usual shape and size, contains a liquid mixed with bile. The gatekeeper is rounded, not fully closed. The bulb of the duodenum is capacious, its mucous is hyperemic, at a distance of 0.2 - 0.3 cm from the pylorus along the greater curvature the choledochodadenal fistula with a diameter of 0.3 cm is defined. fibrin The passage of bile is not broken. The exit section is freely passable, the mucosa of the post-bulbar departments is not changed.

Ultrasound examination of the biliary tract. The liver with even edges, echo structure is not changed, it is not enlarged in size, the intrahepatic bile grooves are visualized. Choledoch 0.3 cm. The gallbladder is oval in shape, its wall is thickened to 0.7 cm, the diameter is 2.7 cm. Without echoes from the cavity.

Externally pancreatic function. The volume of 182 ml (140-190), bicarbonates 102 mg (70-190), total proteinases 927 (557-1135).

X-ray of the gastrointestinal tract. Hook shaped stomach several

deformed by a small cascade in a / z. The mucous in a / s rebuilt in the form of several slightly transverse folds. Peristalsis is traced to the gatekeeper. The last pass. The bulb is reduced in size, deformed. There is a reflux of a small amount of contrast into the common bile duct, which is quickly emptied. The toe of the vertical branch of the duodenum is reduced, stasis is determined at this level. Choledoch is not extended. Evacuation of contrast in the small intestine is not broken.

The proposed method allows to restore the outflow of bile and pancreatic juice and to restore the duodenal patency in the surgical treatment of patients with complicated

postbulbar duodenal ulcers with distal choledochus involved in the pathological process and stenosis.

The method is recommended for practical use.

Claims (1)

The invention The method of surgical treatment of postbulbar duodenal ulcers intestine, including excision of the duodenal segment with the preservation of the pyloric sphincter and the imposition of terminal duodenoanastomosis, characterized in that, in order to restore the outflow bile and pancreatic secretions with lesions of the distal choledochus, the longitudinal dissection of the anterior wall of the stenotic portion of the choledochus is performed. and cut edges are sewn into the back. lip shaped duodenoanastomosis.  FIG. one