RU2143230C1 - Method of surgical treatment of duodenal peptic ulcer - Google Patents

Abstract

FIELD: medicine, surgery; applicable in surgical treatment of duodenal peptic ulcer. SUBSTANCE: method includes selective proximal vagotomy; dissection of tubular stenosis of duodenum; preservation of pylorus; replacement of large defect of proximal part of duodenum by island segment of jejunum. EFFECT: reduced number of postoperative functional disturbances and ulcer recurrences. 4 dwg, 1 ex

Description

 The invention relates to medicine, namely to surgery, and can be used to treat duodenal ulcer complicated by tubular stenosis of the entire proximal part of the duodenum, that is, from the pylorus to the large duodenal papilla.

 The expansion of the arsenal of anti-ulcer drugs significantly limits the indications for stomach-crippling surgical treatments. Long-term “successful” conservative treatment of relapses of duodenal ulcer led to an increase in the proportion of tubular duodenal stenosis, which requires further development of organ-preserving and organ-restoring technologies that guarantee the completeness of functional rehabilitation.

 Frequent relapse of peptic ulcer against the background of increased acid-peptic aggression leads, ultimately, to a complete scar-ulcer transformation of the entire proximal duodenum. According to our data, from the number of patients operated for ulcerative stenosis in 8.4% of patients, radical excision of the post-ulcerous lesion leads to resection of the duodenum from the pylorus to the large duodenal papilla or peri-papillary level.

 Our many years of experience in plastic surgery of complicated duodenal ulcers revealed the dependence of the completeness of restoration of gastroduodenal complex function on the volume of resection of the proximal duodenum.

 The expansion of the resection volume of the proximal part of the duodenum eliminates the advantages of radical duodenoplasty over palliative shunting of stenosis. A decrease in pyloric papillary diastasis, combined with various variants of pyloric lysis, violates gastric autonomy. The absence of a bulboduodenal sphincter and bulb bulb leads to continuous evacuation from the stomach. Compensatory response spasm of distal intestinal sphincters is the cause of duodenostasis of varying severity.

 Thus, the development of new methods of surgical treatment, allowing not only to relieve the patient of the recurrence of duodenal ulcers, but also to eliminate duodenogastric reflux and its consequences - alkaline gastritis, is an urgent task of surgery.

 The method for surgical treatment of duodenal ulcer complicated by prolonged cicatricial ulcerative alteration of the proximal duodenum is taken as an analog.

 Stem vagotomy with gastroduodenoanastomosis. The method is well known, first proposed by Jaboulay in 1892 (cited by A.A.Shalimov, V.F.Saenko, 1987).

 After a laparotomy, the left lobe of the liver is mobilized by dissecting the triangular ligament, the visceral peritoneum of the esophagus-gastric junction is dissected, the right and left vagus nerves are distinguished with subsequent intersection. Then, according to Kocher, the duodenum is mobilized, a vertical branch is brought to the antrum of the stomach, a gastro-duodenal anastomosis with anastomosis diameter of 4-5 cm is formed.

Disadvantages:
1. Complete denervation of the stomach and bypass of the pylorus violate their motor-evacuation function, this leads to the occurrence of dumping syndrome and reflux gastritis.

 2. The complicated ulcer, scar-transformed walls of the bulb, that is, tubular stenosis, which does not exclude further complications of peptic ulcer (bleeding, penetration, perforation), are not removed.

 As a prototype, a method was taken: segmental duodenoplasty with SPV (Onopriev V.I., patent N 971286, priority dated December 15, 1980).

 When performing the prototype method, the duodenum is mobilized, its anterior wall is cut transversely above the ulcer or along the line of maximum narrowing, and the rigid edges of the duodenal wall are excised. Isolation of the walls of the intestine is carried out stepwise up and down. Cicatricial and infiltrated tissues are completely excised. After excision of the stenotic segment of the duodenum, its edges are mobilized and freely reduced to the distal, that is, the papillary end, which allows the papillary anastomosis to be applied without tension. The back wall of the anastomosis is sutured with a single-row regional sero-muscular-submucosal suture 4-6 / 00 nodules inward (absorbable monofilament) or nodules outward (non-absorbable monofilament). The anastomosis anterior wall is sutured with a single-row nodular serous-muscular-submucosal suture (4-6 / 00).

 SPW begins with skeletalization of the esophageal opening of the diaphragm (AML) and its left leg by crossing the esophageal-diaphragmatic, diaphragmatic-cardial and diaphragmatic-fundus ligaments, which allows to extend the esophagus, lower the cardia and the angle of His. Cross the proximal half of the gastro-splenic ligament, pancreas and gastric ligament with blood vessels and nerves. First, the back wall of the esophagus and cardia is skeletonized from behind through a window in the gastro-splenic ligament to the first short artery of the stomach. Then the front wall of the cardia and esophagus is skeletonized, with particular attention paid to the intersection of the branches of the main cardiac nerves. Skeletalization of the lesser curvature of the stomach goes from the cardia to the corner, the "goose foot" of the posterior main gastric nerve is controlled through a window in the gastrocolic ligament at the level of the angle of the stomach. To restore the closure function of the cardia, new anatomical relationships are created between the esophagus, cardia and stomach in the form of an esophago-cardio-gastric valve by lateral invagination with restoration of the ligamentous apparatus.

 Disadvantages: 1. The proximal section of the duodenum is removed to the large duodenal papilla, anastomosis performed under these conditions reduces pyloric papillary diastasis, leading to an increase in duodenogastric reflux and the development of reflux gastritis.

 2. Additional mobilization of the pyloroduodenal end, as well as the anatomical features of the papillary zone of the duodenum determine its rigidity, the formation of pyloroduodenal anastomosis at this level prevents the complete restoration of the function of the pylorus.

 3. The creation of a papillary duodenal anastomosis in case of recurrence of an ulcer along the suture line poses a threat to ulcerative damage to the papilla.

 The aim of the invention is to increase the effectiveness of surgical treatment of duodenal ulcer complicated by tubular cicatricial ulcer stenosis of the proximal duodenum, reduction in the number of postoperative functional disorders and relapse of the ulcer, improving the quality of life of patients in the long term.

 Objective: to develop a method for the surgical treatment of duodenal ulcer complicated by tubular cicatricial and ulcerative stenosis of its proximal section, which involves the radical removal of the damaged segment with preservation of the pylorus, followed by the replacement of an extensive defect of the duodenal wall with a small bowel transplant with restoration of anatomical pyloric papillary diastasis.

 The essence of the proposed method is to restore pyloric papillary diastasis by replacing it with an insert formed from a section of the jejunum on the vascular pedicle of an appropriate size.

 Segmental enteroduodenoplasty is performed as follows. Cicatricial-adhesive mantle is excised and tubular stenosis is discovered throughout. After extensive mobilization of the duodenum along with the head of the pancreas, the nature and extent of scar-ulcerative damage to the walls of the duodenum are specified (Fig. 1). At the distal end of tubular stenosis, transverse duodenotomy 1 is performed and the level of BDS 2 and pylorus 3 is specified. Proximal stenosis is dissected under intraduodenal control to prevent iatrogenic damage to the intact walls of the duodenum and pyloric sphincter. Radically altered cicatricial walls of the duodenum. The intersection of the posterior wall of the bulb under the pylorus is controlled through the pyloropancreatic ligament. The criteria for the sufficiency of excision of the walls of the duodenum are: the preservation of the layers of the left duodenal wall, their good blood supply, free dilatation of the lumen. Observe the extreme precision of excision of the walls of the duodenum in the area of the duodenal papilla 2 and the pyloric sphincter 3 (Fig. 2).

 In the initial section of the jejunum, the most mobile loop is determined. In proportion to the defect between the pylorus and the BDS determine the size of the small intestine transplant 4 (Fig. 3). Using transillumination, the angioarchitectonics of the proposed small intestinal transplant is examined. Arcade vessels limiting the mobility of the intestinal segment are ligated. On the shortest path, from the base of the small intestinal mesentery to the site of the duodenal defect, in the avascular part of the large intestinal mesentery create a "window" with dimensions that exclude compression of the graft mesentery. A segment of the jejunum drawn through the “window” leads isoperistaltically to the site of the duodenal segmental defect. At the same time, his mobility, the correct position of the mesentery are re-controlled, and blood supply is assessed. The "insert" is anastomosed proximal to the periopiloric walls of the duodenum 5 (Fig. 4), distally to the periapical level of the duodenum 6. Apply single-row serous-muscular-submucosal sutures that compress the submucosal layers. The primary formation of a periapical anastomosis allows external ligation of the posterior wall sutures of both duodenal anastomoses. The seam lines are covered with a mobilized strand of a large omentum. The continuity of the jejunum is restored by end-to-end enteroanastomastomosis with a single-row serous-muscular-submucosal suture 7 (Fig. 4).

 After segmental enteroduodenoplasty, selective proximal vagotomy is performed: the cardia is reduced by 1.5 - 3 cm, the abdominal esophagus, cardia and lesser curvature are skeletonized from the angle of the stomach (above the point of entry of the first branch of the distal goose foot of the Letarget nerve).

 Areflux cardia is formed. To do this, the esophagus-cardiac transition is taken onto the holder, create the angle of His by means of a suture that captures the bottom of the stomach, esophagus and the edge of the esophageal opening of the diaphragm (AML) with the remains of the esophageal-diaphragmatic ligament. The esophageal-gastro-diaphragmatic ligaments are restored with three sutures, capturing with two of them the front wall of the bottom of the stomach, the paesophageal tissue and the left leg of the AML and one - the posterior wall of the bottom of the stomach and the left leg of the AML. The method of invagination creates an areflux esophagocardiogastric valve.

 The method was tested on 9 patients. Patient P., 67 years old, was admitted to the clinic of the Republican Center for Functional Surgical Gastroenterology 8.01.97, with a diagnosis of Peptic ulcer. Subcompensated stenosis. Condition after suturing perforated ulcers (84 g.). Condition after segmental duodenoplasty (07.96). Relapse ulcers. An ulcerative history since 1980, in 1984, the disease was complicated by perforation of the duodenal ulcer, about which the operation of suturing the ulcer was performed. In 1995, a laparotomy and dissection of adhesions were performed for adhesive obstruction. In June 1996, isolated segmental duodenoplasty was performed for relapse of duodenal ulcer complicated by subcompensated stenosis. Despite antacid treatment, in December 1996 he noted a deterioration. Upon receipt of a complaint of "hungry" and night pain in the epigastrium and right hypochondrium, a feeling of fullness in the stomach after eating, repeated vomiting, weight loss of up to 10 kilograms. FGDS: the pylorus is dilated, atonic, the bulb is shortened, is represented by a scar-ulcer tubular segment, the output section is narrowed to 0.7 cm, it is difficult to pass through a children's endoscope. On the posterior wall in the stenosis zone, a crater-shaped ulcerative defect with dimensions of 1.0x0.7x0.5 cm. The bottom is made of fibrin. X-ray: the stomach is enlarged (5 cm above the scallop line); the pylorus is dilated, the upper part of the duodenum is shortened, stenosed to 0.5 cm, it is difficult to pass barium. After 4 hours, 2/3 of the barium in the stomach. pH-metry: in the basal period, acid formation of increased concentration, increased intensity. Decompensated alkalization. Operated on 01/21/97. An intraoperative study revealed a shortening of the gastroduodenal junction with severe pancreatic head infiltration. Express diagnostics and ultrasound examination to exclude the oncological process. Intraduodenally found: two ulcerative craters on the posteromedial and posterolateral walls in the post-bulbar level, cicatricial transformation of the posterior wall from the basal to post-bulbar levels. Resection of the modified walls of the duodenum. The gatekeeper retained the bare distal portions of the upper sector. The large duodenal papilla is present to the line of resection (the total mouth is 0.5 cm distal). A section of the jejunum was mobilized with a length of 8 cm while maintaining its blood supply and extraorganic innervation. The continuity of the intestine was restored by a single-row suture. The selected area is isoperistaltically anastomosed with a proximal basal-pyloric level of duodenum and distal post-bulbar. Anastomoses are made end-to-end by a single-row nodular monolithic serous-submucosal suture with external ligation.

 Selective proximal vagotomy was performed simultaneously. The abdominal esophagus, cardia and fundus of the stomach were mobilized, denervation and devascularization of lesser curvature to the angle of the stomach was performed while maintaining the antral innervation.

 Cardia areflux restored by creating an invagination esophagocardiogastric valve. Peritonization of lesser curvature. Suture on the stomach and duodenum. For postoperative decompression, a nasogastric polyvinyl chloride probe was performed.

 The postoperative period was uneventful. On the 5th day, the nasogastric tube was removed and allowed to eat. Discharged from the hospital on the 12th day after the operation. Examined after 6 months. He did not make complaints during the examination, he did not follow a diet. With FGDS: the stomach of the usual form is slightly enlarged, in the lumen of the mucus without impurity of bile. The gatekeeper is deformed in the upper front sector, does not close completely. The unchanged mucosa of the small intestine transplant prolapses into the stomach. The large duodenal papilla borders the line of the enteric-duodenal anastomosis. BDS is 7 cm from the pyloric line. On R-scopy: portioned evacuation of contrasted food from the stomach, with complete emptying for 1.5 hours. The R-anatomy of the created gastroduodenal transition corresponds to normal proportions. Peristalsis of the intestinal "insertion" is observed. 6 months after the operation, he feels well, does not follow a diet, works in the same place.

 Using the method allows to achieve the cure of duodenal ulcer complicated by prolonged cicatricial ulceration. The high functionality of the proposed operation allows you to quickly restore full gastric digestion, provides portioned food advancement in the upper gastrointestinal tract, and prevents the development of reflux gastritis and post-vagotomy disorders. Thus, the application of the method leads to a quick and reliable recovery of patients, provides them with a high quality of life.

Claims (1)

 A method for surgical treatment of duodenal ulcer, including selective proximal vagotomy, segmental excision of tubular stenosis of the duodenum, preservation of the pylorus, characterized in that an extensive defect at the site of the damaged proximal duodenum is replaced by a segment of the jejunum on the vascular pedicle, and diastasis between the duodenal papilla is expanded.

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