RU2289324C1 - Method for treating duodenal stump at gastric resection to exclude the ulcer - Google Patents

Abstract

FIELD: medicine, urgent abdominal surgery.

SUBSTANCE: one should squeeze with a clamp an antral gastric department at the distance of about 4-5 cm against pylorus, below the clamp one should dissect both serous and muscular membranes up to mucosa to apply a clamp onto stump's mucosa; serous and muscular membranes should be separated against mucosa up to pylorus; then it is necessary to remove the mucosa of antral gastric department, dissect anterior fragment up to pylorus, suture in duodenal mucosa with mucous-submucous sutures, suture together pyloric muscular membrane and that of posterior fragment; posterior fragment should be inverted to the right to be sutured to pylorus and duodenum. At anterior pyloric wall one should make incisions of serous membrane being parallel to circular fibers; through both incisions in muscular layer it is necessary to fulfill tunnelization bluntly, direct posterior fragment into the tunnel. Incisions of serous membrane in peculiar case should be fulfilled at the length of 3.5-4.0 cm. The method keeps circulation and stump's hermetic nature.

EFFECT: higher efficiency.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to emergency abdominal surgery, and can be used in the treatment of the duodenal stump during resection of the stomach to turn off the ulcer.

There is a method of treating a duodenal stump (Wilmans method), in which the antrum of the stomach is pressed with a clamp at a distance of 4-5 cm from the pylorus and below the clamp, the serous and muscle membranes are cut to the stump mucosa, then a clamp, serous and muscle are applied to the mucous membrane of the stump the membranes are separated from the mucous membrane to the pylorus, where the mucous membrane is ligated and cut off above the ligature, after which the antrum serous-muscular is sutured over the stump of the mucous membrane the tube with U-shaped sutures (see A.A. Shalimov, A.P. Radzikhovsky. Atlas of operations on the digestive organs, Volume 1, Kiev, Naukova Dumka, 2003).

The reasons that impede the achievement of the following technical result when using the known method include insufficient tightness of the duodenal stump due to a violation of the blood supply to the duodenal stump during its mobilization.

The closest method of the same purpose to the claimed invention in terms of features is a method of treating a duodenal stump during gastrectomy to turn off an ulcer, by which the antrum of the stomach is pressed with a clamp at a distance of 4-5 cm from the pylorus, the serous and muscle membranes are cut to the mucosa below the clamp , a clamp is applied to the mucous membrane of the stump, the serous and muscle membranes are separated from the mucous membrane to the pylorus, the mucous membrane of the antrum is removed ka, after which the anterior flap to the pylorus is excised, the mucous membrane of the duodenum is sutured with mucous-submucosal sutures and the muscle membrane of the pylorus and the posterior flap is sutured, which is wrapped to the right and sutured to the pylorus and duodenum (see A.A. Shalimov, A.P. Radzikhovsky. Atlas of operations on the digestive organs, Volume 1, Kiev, Naukova Dumka, 2003), adopted as a prototype.

The reasons that impede the achievement of the technical result indicated below when using the known method adopted as a prototype include insufficient tightness of the duodenal stump due to a violation of the blood supply to the duodenal stump during its mobilization.

The objective of the invention is to provide a method of treating a stump of the duodenum during resection of the stomach to turn off the ulcer, providing a technical result, which consists in maintaining the blood supply and tightness of the stump.

The specified technical result in the method of processing the duodenal stump during gastrectomy to turn off the ulcer is achieved by clamping the antrum of the stomach at a distance of 4-5 cm from the pylorus, dissecting the serous and muscle membranes to the mucosa below the clamp, applying a clamp to the mucous membrane of the stump, the serous and muscle membranes are separated from the mucous membrane to the pylorus, the mucous membrane of the antrum is removed, after which the anterior flap to the pylorus is excised, sutured the mucous membrane of the duodenum with mucous-submucosal sutures and sutured the muscle membrane of the pylorus and posterior flap, which is wrapped to the right and hemmed to the pylorus and duodenum.

The peculiarity lies in the fact that on the front wall of the pylorus, serous membranes are cut parallel to the circular fibers, through both cuts in the muscle layer they stupidly tunnel and a posterior flap is made into the tunnel.

Also a feature of the method is that the incisions of the serous membrane produce a length of 3.5-4.0 cm

The invention is illustrated by drawings, where figure 1 shows the volume of the resection of the stomach and the line of intersection of the stomach and duodenum, figure 2 - the stump of the duodenum (dashed line shows the cut-off line of the front flap of the duodenum), figure 3 - front flap of the duodenum fixed by interrupted sutures to the posterior flap, in Fig. 4, the posterior flap is guided into the tunnel, the tunnel in the muscle layer, Fig. 5 is the tunnel in the muscular layer, and the posterior flap is guided into the tunnel.

The method is as follows.

Squeeze the antrum of the stomach with a clamp at a distance of 4-5 cm from the pylorus. Below the clamp dissect the serous and muscle membranes to the mucosa (figure 1). A clamp is applied to the mucous membrane of the stump, and the serous and muscle membranes are separated from the mucous membrane to the pylorus. The mucous membrane of the antrum is removed, after which the anterior flap 1 to the pylorus is excised (Fig. 2). Sutured the mucous membrane of the duodenum with mucous-submucosal sutures. Then the muscle membrane of the pylorus and the posterior flap 2 are sutured (Fig. 3). On the front wall of the pylorus, sections of the serous membrane are produced with a length of 3.5-4.0 cm parallel to the circular fibers. Through both sections in the muscle layer, tunneling is stupidly carried out. The back flap 2 is wrapped to the right, carried out into the tunnel 3 (figure 4), hemmed to the pylorus and duodenum (figure 5).

Clinical example

Patient M., 45 years old, was admitted to the 6th surgical department of the Ulyanovsk City Clinical Hospital for Emergency Medicine on October 17, 2004 at 13 h with a diagnosis: "Duodenal ulcer complicated by penetration." Upon admission, the patient complained of pain in the upper abdomen of herpes zoster, nausea. Sick for two weeks. I applied for an ambulance, was taken to the admission department of the Ulyanovsk City Clinical Hospital for Emergency Medicine.

Since 1996, he suffers from peptic ulcer of the duodenum, has repeatedly undergone conservative treatment in hospitals of the city. In 1997, he underwent suturing of a perforated duodenal ulcer. On examination: the general condition of the patient is relatively satisfactory. The skin is moist, normal color. The pulse is satisfactory filling and voltage 74 beats per minute. Blood pressure 130/80 mm Hg The tongue is moist, covered with a brown coating. The abdomen is of the correct form, not swollen, symmetrical, participates in the act of breathing. On palpation, soft, painful in the epigastric region. Hepatic dullness is present. There is no dullness in the sloping places of the abdominal cavity. Intestinal motility is active. Symptom Shchetkina-Blumberg negative. Done - esophagogastroduodenoscopy protocol 10/17/2004. Esophagus freely pass. In the cavity of the stomach a moderate amount of bile. In the duodenal bulb, severe cicatricial deformity. Below the bulb on the posterior wall of the duodenum there is an ulcer of 1.3 x 0.6 cm in size covered with fibrin. Conclusion: duodenal ulcer complicated by penetration. Diagnosed with peptic ulcer of the duodenum, complicated by penetration into the pancreas.

In the preoperative period, the patient received antiulcer therapy.

Operation: 10/22/2004 10 h 15 min - 12 h 50 min. The operation revealed: severe cicatricial deformity of the duodenal bulb, perigastritis, periduodenitis, below the ulcer bulb on the posterior wall of the duodenum. It was decided to perform a resection of the stomach to turn off the ulcer. Produced: resection of the stomach according to Billroth-II with transverse gastroenteroanastomosis. The duodenal stump was treated according to the method of Wilmans with plastic serous-muscle flap by tunneling. The postoperative period was uneventful, smooth.

In satisfactory condition on November 4, 2004, the patient was discharged from the hospital under the supervision of a surgeon in the clinic at the place of residence. Inspected on May 22, 2005. His condition is good. No complaints. It works in the same place. Esophagogastroduodenoscopy, protocol 05.22.2005. The esophagus is freely passable. In the cavity of the stump of the stomach a small amount of clear fluid. Mucous pink. The area of the anastomosis without inflammatory changes, freely pass. Conclusion: Condition after gastrectomy by Billroth-II with transverse gastroenteroanastomosis. An ultrasound examination of the abdominal organs revealed no pathology.

Thus, the use of the proposed method for the treatment of duodenal stump during resection of the stomach to turn off the ulcer ensures the preservation of blood supply and tightness of the stump.

Claims (2)

1. A method of treating a duodenal stump during gastrectomy to turn off an ulcer, which consists in clamping the antrum of the stomach at a distance of 4-5 cm from the pylorus, dissecting the serous and muscle membranes to the mucosa below the clamp, applying a clamp to the mucous membrane of the stump, the serous and muscle membranes are separated from the mucous membrane to the pylorus, the mucous membrane of the antrum is removed, after which the anterior flap to the pylorus is excised, the mucous membrane is sutured twelve duodenal ulcer by mucous-submucosal sutures and sew the muscle membrane of the pylorus and posterior flap, which is wrapped to the right and stitched to the pylorus and duodenum, characterized in that on the front wall of the pylorus, serous membranes are cut parallel to the circular fibers, bluntly through both cuts in the muscle layer tunneling and spend in the tunnel back flap. 2. The method according to claim 1, characterized in that the incisions of the serous membrane produce a length of 3.5-4.0 cm

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