RU2255672C2 - Method for reduodenization in case of disease of operated stomach - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should conduct superior-median laparotomy, resection or extirpation of stomach's stump, form a "new" stump or artificial stomach out of jejunal transplant at applying gastroduodeno- or jejunoduodenoanastomosis. For this purpose one should exfoliate muscular membrane from submucous posterior and median wall of duodenal stump so, that it should remain at the pancreatic caput. One should mobilize proximal duodenal part, form invagination-valvular jejunoduodeno- or gastroduodenoanastomosis by "end-to-end" type. This technique enables to prevent intraoperation trauma of common bile duct and minimize pancreatic trauma, as well.

EFFECT: higher efficiency of reduodenization.

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Description

The invention relates to the field of medicine, surgery, and specifically to a method of reduction in diseases of the operated stomach.

Most authors point to the significant technical complexity of the first stage of the operation of reduction, one of the points of which is the search and isolation of the duodenal stump [1; 4; 5] due to the severity of the adhesive process in the abdominal cavity and cicatricial changes in the posterior and medial walls of the duodenal stump.

With a deep location of the duodenum and the presence of dense cicatricial adhesions, mobilization can cause certain difficulties and this greatly complicates the technique of applying gastroduodenal or eunoduodenal anastomosis. When dissecting adhesions in the area of the duodenal stump, it is necessary to be careful of damage to the gallbladder and especially the common bile duct [1].

Of the 130 patients who underwent reduction (1), the absence of adhesions in the duodenum was observed in 17, small adhesions in 31, pronounced adhesions in 52, stump expansion in 14, narrowing in 9 and, finally, thinning of the walls in 7 patients.

Closest to the proposed method is a reduction of [2] in case of an illness of the operated stomach, G. D. Vilyavin and B. A. Berdov (1975), according to which the gastro-union anastomosis is resected and the end-to-side gastroduodeno- or eunoduodenoanastomosis is formed in the vertical part KDP. However, in this case, the method of forming the anastomosis is forced and at the same time there are conditions for reflux of the duodenal contents into the stump of the stomach or graft, which entails the appearance of an illness of the operated stomach.

A new technical task is to reduce the number of complications due to the prevention of wounds of the common bile duct and pancreas, as well as reflux gastritis (reflux conjunction).

The problem is solved by a new method of reduodenization in diseases of the operated stomach, including upper median laparotomy, resection or extirpation of the gastric stump, followed by the formation of a “new” stump or artificial stomach from a jejunum transplant with the application of gastroduodeno or jeunoduodenoastomastosis, with from the submucosal posterior and medial walls of the stump of the duodenum, the proximal site is mobilized latter and forming invaginated-valve eyunoduodeno- gastroduodenoanastomoz type or end to end.

The method is as follows: from the upper median access, resection or extirpation of the stump of the stomach is performed. The front wall of the duodenal stump is isolated by dissecting adhesions (Fig. 1), taken onto the holders along the upper contour and stretched up and to the right (Fig. 2). In the transverse direction, the serous-muscular membrane is dissected over the entire width of the stump (Figure 3). Then, using the precision technique, the muscle membrane of the posterior stump wall is separated in such a way that it remains on the head of the pancreas. In this case, the tension of the duodenal stump for the holders allows you to clearly visualize the vessels of the submucosal base of the duodenum, under the control of vision, apply clamps to them and bandage them (Figure 4). Thus, 15-18 mm of the submucosa of the posterior wall of the duodenal stump is released. On the front wall of the duodenal stump, the serous-muscular membrane is removed along the same length (Figure 5). A mobilized area of the duodenum is sufficient for the formation of an invagination valve, which is applied according to the previous procedure [3].

The operation is completed by holding a microprobe into the jejunum below the anastomotic zone and the probe into the stomach stump or transplant for decompression.

Clinical example 1.

Patient S., 45 years old, was treated at the Research Institute of Gastroenterology from 02/02 to 02/21/2002 with a diagnosis of duodenal ulcer, condition after resection of 2/3 of the stomach according to Billroth II from 04.1997, severe dumping syndrome.

From the anamnesis: in April 1997, a resection of 2/3 of the stomach was performed according to Billroth II for a duodenal ulcer complicated by bleeding. In the postoperative period, severe dumping syndrome arose that did not respond to conservative therapy. A decision was made to perform a reconstructive operation.

On admission: satisfactory condition, pathology from the internal organs not found, peripheral l / y not increased, distant metastases were not found.

After preoperative preparation, the patient was operated on. 02.12.2002, the operation was performed: resection of the gastric stump with the zone of gastroenteroanastomosis, the formation of invagination-valvular gastroduodenoanastomosis according to the claims.

The postoperative period is smooth, healing by primary intention, probe nutrition for up to 6 days. On the ninth day after surgery, in satisfactory condition, was discharged for outpatient treatment.

1 year after surgery: satisfactory condition, no complaints. FEGDS: the esophagus is not changed, the cardia is closed, in the cult of the stomach a moderate amount of mucus without impurity of bile. Anastomosis with the duodenum is closed end to end, freely passable, the mucosa in the anastomotic zone is not changed.

Clinical example 2:

Patient M., 55 years old, was treated at the Research Institute of Gastroenterology from January 14 to February 1, 2002 with a diagnosis of duodenal ulcer, condition after resection of 2/3 of the stomach from November 1999, peptic ulcer of gastroenteroanastomosis complicated by bleeding (2000, 2001). From the anamnesis: in November 1999, a resection of 2/3 of the stomach was performed for duodenal ulcer, complicated by stenosis of the output section of the stomach. After the operation, a peptic ulcer of the gastroenteroanastomosis arose, complicated by bleeding. Currently, with FEGDS there is an ulcer in the zone of gastroenteroanastomosis, 2.5 cm in diameter.

On admission: satisfactory condition, pathology from the internal organs not found. The abdomen is calm, pathological formations are not determined. An examination revealed a focal formation in the area of the pancreas tal (gastrinoma?).

After preoperative preparation, the patient was operated on. 01/22/2002 operation: extirpation of the stump of the stomach, enucleation of gastrinoma, reconstructive eunogastroplasty with the formation of invagination-valvular eunoduodenoanastomosis according to the claims.

The postoperative period is smooth, healing by primary intention, probe nutrition for up to 6 days. On the tenth day after the operation in satisfactory condition, the patient was discharged for outpatient treatment.

FEEDS from 01.28.2003: the esophagus is not changed, the anastomosis with the jejunum is closed, swollen with air up to 1.5 cm, freely passable, the length of the graft is about 15 cm, its appearance is characteristic of the jejunum. Anastomosis with duodenum is closed, we pass freely for the apparatus of 11 mm. The mucosa in the anastomotic zone is not changed.

Cross-probe duodenography dated January 30, 2003: a contrast agent was introduced through a microprobe into the transplant, the latter is fed portionwise into the duodenum, the opening of the anastomosis is up to 15 mm. The casting of contrast in the transplant from the duodenum is not observed.

According to the proposed method, 10 patients aged 36 to 72 years were operated on. The indications for the reduction were: severe dumping syndrome (2), peptic ulcer of gastroenteroanastomosis after Billroth II operation (3), severe reflux gastritis (2), as well as a combination of moderate dumping syndrome and peptic ulcer of gastroenteroanastomosis (3) . Extirpation of the stomach stump was performed in 4 patients, resection in 6 patients. No complications were observed in the early postoperative period.

All patients in the early and long-term postoperative period underwent a set of examinations, including laboratory and instrumental methods of research. A total of 9 patients were examined in the distant postoperative period.

The results of an endoscopic examination of patients 6 months after surgery: there are no changes in the esophagus, its mucosa is not changed, the anastomosis is closed, we pass freely, when it is inflated, it opens up to 12-14 mm. The type of transplant mucosa is characteristic of the small intestine, the usual color with transverse folds, the contents of mucus, bile no. Anastomosis with duodenum closes, opens when insufflated with air. The tube of the 11 mm device runs freely in the KDP.

An X-ray examination after six months: the contrast mass passes freely through the esophagus, the anastomosis peristalsis, opening up to 20 mm. After extirpation of the stump, a conical-shaped transplant with a gas bubble in the proximal region is shown in FIG. 5. The transverse size of the graft expanded to 5-6 cm more in the upper part. Evacuation of contrast in the duodenum occurs after 3-4 minutes. Eunoduodenoanastomosis peristalsis, opening to every 3-4 peristaltic waves up to 2.5 cm. After an hour and a half in the graft there are traces of contrasting mass, most of it in the loops of the jejunum.

The content of bile acids in the graft was equal to their normal content in a healthy stomach.

After 2-3 months, patients switched to a common table and 3-4 meals a day.

Thus, the proposed method of reduodenization in diseases of the operated stomach allows preventing intraoperative wound of the common bile duct, minimizing pancreatic injury, as well as the occurrence of a number of post-gastroresection disorders associated with the method of formation of jeunoduodeno- or gastroduodenoanastomosis in the long term.

Captions to figures.

Figure 1. Isolation of the duodenal stump from adhesions.

Figure 2. The duodenal stump is taken to the holders. Beginning of stump separation.

Figure 3. Dissected serous-muscular membrane over the entire width of the stump.

Figure 4. Ligation of the vessels of the submucosal layer of the posterior wall of the duodenal stump.

Figure 5. Removal of the serous-muscular membrane of the anterior wall of the duodenal stump.

Literature.

1. Busalov A.A., Komorovsky Yu.T. Pathological syndromes after resection of the stomach. M .: Medicine. - 1966. - 240 p.

2. Vilyavin G.D., Berdov B.A. Diseases of the operated stomach. - M.: Medicine. - 1975 .-- 296 p.

3. Zherlov G.K., Koshel A.P. Primary and reconstructive eunogastroplasty in the surgery of diseases of the stomach. - Publishing house of TSU. - 1999. - 212 p.

4. Zakharov E.I., Zakharov A.E. Eunogastroplasty in diseases of the operated stomach. M .: Medicine. - 1970. - 232 p.

5. Komorowski Yu.T. Resection of the stomach with small bowel plastics: Abstract, Diss. Doct. honey. sciences. - Lviv. - 1964. - 25 p.

Claims (1)

A method of reduction of an illness in an operated stomach, including upper median laparotomy, resection or extirpation of a gastric stump followed by the formation of a “new” stump or artificial stomach from a jejunum transplant with the application of gastroduodeno or jeunoduodenoanastomosis, characterized in that gastro-muscular neoplasm is applied for application from the submucous posterior and medial walls of the stump of the duodenum so that it remains on the head of the pancreas, mobilize the maximal section of the duodenum and form an invagination-valvular jeunoduodeno- or gastroduodenoanastomosis according to the “end to end” type.

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