RU2522967C2 - Method for closure of duodenal stump - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery. A duodenum is dissected away from a stomach. A continuous through suture is applied on a duodenal stump. The first suture is immersed under a surrounding purse suture. The purse suture is tightened without hermeticity. An adjacent organ covered by the peritoneum is anchored to the stump with interrupted seromuscular sutures. The interrupted suture filaments are brought under the purse suture filaments. A method enables closing the duodenal stump if observing an evident enteral oedema in patients with portal hypertension.

EFFECT: reduced risk of suture cutting and stump blood supply disturbance.

2 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of stomach ulcers and duodenal ulcers in the presence of severe edema of the tissues of the stump of the intestine, in particular if the patient has portal hypertension.

In recent years, the incidence of liver cirrhosis has been steadily increasing. One of the common complications of cirrhosis is the so-called. hepatogenic ulcers. The frequency of gastroduodenal ulcers with cirrhosis is up to 21.6%. According to various sources, from 61 to 90% of cases of bleeding with portal hypertension due to cirrhosis of the liver are caused by ulceration of the upper gastrointestinal tract (Uspanova G. Abstract of Cand. Diss. N. Novgorod, 2006). One of the methods for treating hepatogenic ulcers is Billroth 2 distal gastric resection.

The resection of the stomach according to the method of Billroth 2 suggests the need for suturing the stump of the duodenum. The development of stump insolvency - one of the main causes of death after resection of the stomach according to Billroth 2 - largely depends on the method of suturing the stump. Portal hypertension with cirrhosis of the liver leads to difficulty in the outflow of venous blood, lymph from the organs of the gastrointestinal tract, in particular from the stomach and duodenum. The result is swelling and infiltration of the intestinal wall. Tissues are easily vulnerable, there is increased bleeding, a tendency to teething sutures. Against this background, suturing of the duodenal stump during gastrectomy presents significant difficulties. Existing methods of suturing the stump of the duodenum in such conditions are not always applicable, or their reliability is reduced. This leads to an increase in the incidence of stump failure and an increase in postoperative mortality.

The classic method is the closure of the duodenal stump proposed by Toprover (Shalimov A.A. Polupan V.N. Atlas of operations on the esophagus, stomach and duodenum. “Medicine”, Moscow, 1975, p. 256).

A second clamp is applied over a clip that grips both walls of the duodenum. A duodenum is sewn with a continuous continuous catgut suture, grabbing both clamps into the stitch. The stump is covered with a napkin and the intestine is pressed below the clamp. First remove the upper clamp, and then part and remove the branches of the second clamp. The upper clamp is necessary so that the branches of the lower one are opened after the application of the twisting seam. Pulling the threads (at first alternately) hermetically sutured the stump of the intestine. A purse-string silk seam is placed at the base of the seam. Catgut yarns are tied and the stump is immersed in a purse string suture. For tightness impose another purse-string serous-muscular suture with silk.

When using this method, against the background of edema of the intestinal wall, the purse string suture either cannot be tightened at all due to tissue eruption, or excessive tissue tension arises, which is fraught with eruption subsequently. In addition, a tightly tightened suture violates the already inadequate blood supply to the walls of the intestine.

One of the ways to solve this problem is to use plastic methods of sheltering the duodenal stump. In particular, methods are known for covering the stump with a serous-muscle flap on a vascular pedicle cut out of the stomach. With portal hypertension, the wall of the stomach is also swollen, infiltrated, cutting out the flap takes a lot of time, lengthens the operation, which is undesirable in this category of seriously ill patients. There is also a risk of flap necrosis due to poor blood supply.

In addition, it was proposed to use a round ligament of the liver to cover the tissue of the duodenum.

In the literature on methods for suturing the stump of the duodenum with distal gastrectomy according to Billroth 2, there are no publications focusing on the features of this operation for cirrhosis of the liver with portal hypertension. The prototype of the claimed invention is the "Method of suturing the stump of the duodenum" (RF patent No. 2308238, IPC A61B 17/00, publ. 10/20/2007).

The essence of the prototype is that the lumen of the stump is closed by stitching the front and back walls. At the same time, the first row of sutures and the ulcer defect are covered with the entire thickness of the round ligament of the liver by stitching from the right to left all its tissues in the transverse direction. Then the capsule of the pancreas above the upper pole of the ulcer defect and the serous-muscular anterior wall of the stump are sutured with the same needle. Retreating 2.5-3.0 cm below the first ligature, impose a second ligature, stitching an identical round ligament of the liver, followed by suturing the pancreatic capsule below the lower pole of the ulcer and the serous-muscular anterior wall of the stump. With a large size of the ulcer defect, after tying these ligatures in the spaces between them, additional serous-serous sutures are applied: on the left side between the peritoneal cover of the round ligament of the liver and the lateral edge of the ulcer, on the right side between the peritoneal cover of the round ligament of the liver and the anterior wall of the stump.

The disadvantage of this method in relation to resection of the stomach against the background of portal hypertension is the unreliability of the sutures that fix the ligament to the intestine, in the part where they pass through the edematous, loose tissue of the intestinal wall. In this case, the probability of eruption of the seams is high. In addition, with portal hypertension, the use of a round liver ligament may be impossible or difficult (edema, infiltration, the presence of developed venous collaterals).

The claimed invention solves the problem of creating a simple, reliable and quickly feasible method of suturing the stump of the duodenum with distal stomach resection according to Billroth 2 against cirrhosis of the liver with portal hypertension.

The technical result of the claimed invention is to simplify the method, reduce the time of surgery, reduce its invasiveness by eliminating the eruption of sutures and impaired blood supply to the stump with distal resection of the stomach according to Billroth 2 against cirrhosis of the liver with portal hypertension.

This technical result is achieved by the fact that when suturing the stump of the duodenum, including the intersection of the duodenum, closing its lumen by stitching, followed by suturing of the tissues of a nearby organ, it is new that when crossing the duodenum, it is cut off from the stomach, and stitching is performed by applying a continuous through suture on the anterior and posterior walls through all layers of the duodenal stump and by immersing it under the serous-muscular purse string suture placed around the first suture the tightening of its unsealed first continuous through seam, whereupon nearby suturing body tissue, covered by the peritoneum, the stump duodenum nodal sero-muscular sutures, threads are carried by purse-string suture thread.

A detailed description of the proposed method and examples of its practical implementation

Figure 1-6 shows the stages of the method, where positions 1, 2 are the anterior and posterior walls of the duodenum, 3 is a continuous suture through all layers of the intestinal wall, 4 is a serous-muscular purse string suture, 5 is a nearby organ covered with a peritoneum, for example, gall bladder, 6 - nodular sero-muscular sutures. After mobilization of the duodenum and cutting it off from the stomach, a continuous suture 3 is applied across the front wall 1 and back wall 2 of the stump 3 through all layers of the intestinal wall (Fig. 1). After tightening the suture 3, which is done on the basis of preserving the integrity of the tissue and excluding the eruption of tissue, a serous-muscular purse string suture 4 is applied around the suture (Fig. 2). The purse string suture 4 is tightened without sealing the suture 3 also as much as the edematous tissues of the intestinal wall allow, excessive tension and teething are not allowed. At the same time, the line of passage of the first seam 3 (Fig. 3) is immersed under the purse string suture, but without applying efforts to achieve its sealing. The final cover of the stump is achieved by suturing with nodular sero-muscular sutures 6 of a nearby organ 5, covered with a peritoneum, such as the gall bladder. When flashing the wall of the intestinal stump, the suture threads 6 are held under the purse string suture 4 thread (Fig. 4, 5, 6).

Example 1. Mr. Boy entered the intensive care unit of the City Clinical Hospital No. 1 in Cheboksary on February 24, 2012 with gastrointestinal bleeding. Sick for 3 days. Complaints of severe general weakness, nausea, repeated vomiting of blood, repeated black loose stools. There is no ulcerative history; there are indications of prolonged alcohol abuse. On examination: pallor of the skin, tachycardia up to 115 beats per minute, blood pressure 100/70 mm Hg In a general blood test, hemoglobin is 42 g / l. In case of emergency PEGF, varicose veins of the esophagus of 2-3 tbsp., Erosive esophagitis, superficial mucosal defect of the antrum of the stomach along the lesser curvature with a fixed blood clot continuing parenchymal bleeding were revealed. Ultrasound of the abdominal organs - diffuse changes and enlargement of the liver, splenomegaly. Intensive infusion-transfusion, hemostatic, hepatotropic therapy has been started in the intensive care unit. 01/25/2012, on the nasogastric tube leakage of fresh blood. Surgical treatment is proposed, which the patient categorically refused. FEGDS from 01.25.2012, varicose veins of the esophagus 3 tbsp. trunk type, on the posterior wall of the duodenum ulcer defect 1.2 by 1.0 cm deep to 0.2 cm under a clot, from which blood leaks. Endoscopic hemostasis. The patient's condition progressively worsened - the probe had fresh blood, a pulse of up to 110 per minute of weak filling, blood pressure 80/60 mm Hg, hemoglobin against a background of red blood cell transfusion of 52 g / l. The consent of the patient to the operation is obtained. 01/25/2012, Operation. Due to the extremely serious condition of the patient, gastroduodenotomy, flashing of an acute duodenal ulcer, ligation of the right gastric artery, debridement and drainage of the abdominal cavity were performed. In the postoperative period, the patient's condition remained severe. There were signs of liver failure. 01/30. - bleeding along the drainage of the abdominal cavity. Operation - Relaparotomy, stopping bleeding from varicose veins of the gates of the liver, tamponade of the subhepatic space.

Hepatic insufficiency increased in dynamics, ascites appeared, and total left-sided pneumonia developed.

9.02. peritoneal symptoms appeared. The patient is taken for surgery for health reasons. Performed relaparotomy, revealed insufficiency of gastroduodenotomy sutures. Resection of 2/3 of the stomach according to Billroth 2 in the modification of Hoffmeister-Finsterre. The duodenal stump is sharply infiltrated, swollen. Pronounced expansion of the veins. After applying a continuous suture through all layers of the intestine, a purse-string serous-muscular suture was applied. Based on the condition of preserving the integrity of the tissue of the stump of the duodenum, eliminating the eruption of its thread with a purse string suture, the latter is not fully tightened with immersion of the first row of sutures, but without achieving hermeticity. To the thus formed stump, the gall bladder is hemmed with serous-muscular interrupted sutures, with the capture of a purse-string suture.

In the postoperative period, the patient's condition remained extremely difficult. Peristalsis appeared on the 2nd day after surgery, on the 3rd day - stool after stimulation. The dynamics of increased hepatic, pulmonary-heart failure, encephalopathy of mixed origin, the phenomena of pneumonia persisted. Intensive therapy was carried out, including infusion-transfusion, detoxification, hepatotropic, symptomatic therapy, debridement bronchoscopy, antibiotics. The patient's condition slowly improved, stabilized. On the 9th day after the second operation, the patient was transferred to the hepatology department for further treatment. In the control FEGDS, varicose veins of the esophagus of the 3rd degree, signs of gastritis of the gastric stump, anastomositis were revealed. The patient was discharged home in satisfactory condition under the supervision of a therapist. Recommended course treatment in the Department of Hepatology with the solution of the issue of endoscopic correction of varicose veins of the esophagus.

Example 2. B-naya V-va, 53 years old, was admitted to the hepatology department of the City Clinical Hospital No. 1, Cheboksary, with a diagnosis of chronic viral hepatitis B, active phase, liver cirrhosis with portal hypertension syndrome. The patient noted general weakness, nausea, periodic aching dull pain, "heaviness" in the right hypochondrium. A peptic ulcer history is denied, viral hepatitis was diagnosed 6 years ago, 10 years ago she underwent cholecystectomy for acute calculous phlegmonous cholecystitis. When examining a patient skin, mucous membranes, pulse 72 in 1 minute of satisfactory filling and tension, blood pressure 110/70 mm Hg In the general analysis of blood: red blood cells 3.9 × 10 12 / l, hemoglobin 100 g / l. In biochemical blood agnalysis, bilirubin is 42 μmol / L, a moderate increase in hepatic transaminases. Ultrasound OBP - moderate diffuse enlargement of the liver, spleen, the presence of effusion in the lower abdominal cavity in a small amount. On the 4th day of treatment, the patient's condition suddenly sharply worsened - severe general weakness, cold sweat, dizziness, multiple liquid black stools. The skin is pale, pulse up to 110 per minute, blood pressure 80/60 mm Hg The patient was transferred to the intensive care unit. During emergency esophagogastroduodenoscopy revealed: varicose veins of the esophagus of the 2nd degree with the phenomena of esophagitis, the mucous membrane of the duodenum is swollen, hyperemic, fresh blood in the lumen, on the anteromedial wall of the intestine with a slit-like ulcer up to 1.2 cm long, partially covered by a clot from which leaking fresh blood. Hemoglobin 76 g / l. Endoscopic hemostasis was performed, a nasogastric tube was installed, hemostatic, antisecretory therapy, infusion of freshly frozen plasma, and erythrocyte mass were prescribed. Against the background of the treatment, the patient's condition improved, stabilized, but after 7 hours a clinic of recurrent gastrointestinal bleeding appeared. After short-term intensive preoperative preparation, the patient was taken into the operating room for emergency surgery. During the operation, a marked adhesion process was revealed: a large omentum, duodenum and transverse colon were soldered to the lower surface of the liver. The tissues are infiltrated, the veins of the omentum, duodenum are dilated, easily wounded, and if damaged, severe bleeding occurs. The duodenum and stomach were isolated from adhesions. It was decided to perform a resection of the stomach according to Billroth 2. After mobilization of the stomach and cutting it off from the duodenum below the ulcer, the anterior and posterior wall of the duodenum are sewn together by a continuous suture. The intestinal wall is swollen, infiltrated, when tightening the suture, the tension of the tissues is noticeable, therefore, the tightening force is selected based on the condition of maintaining the integrity of the tissues, eliminating their eruption. Around the tightened continuous seam, departing from it 0.7 cm, a purse string suture was made, tied, immersed, but without sealing the first row of seams, based on the condition for the exclusion of tissue eruption. In the projection of the stump of the duodenum, a round ligament of the liver is stitched with the capture of its tissues with a volume of about 2.0 cm in diameter. The wall of the stump with serous-muscular capture of its tissues was stitched with the same needle and thread, moreover, the thread was held under the previously imposed purse string suture. A total of 6 stitches were sewn. As a result, the duodenal stump was closed with the entire thickness of the stitched part of the round ligament of the liver. The duration of suturing of the duodenal stump was 20 minutes. After suturing the stump of the duodenum, 2/3 of the stomach was resected according to Billroth 2 in the modification of the Hoffmeister-Finster. The course of the early postoperative period is severe. The patient was in the anesthesiology and intensive care unit. Gradually her condition improved. There were no complications. 9 days after surgery, the patient in satisfactory condition was transferred to the hepatological department of the hospital for further treatment of the underlying disease.

Claims (1)

A method of suturing the stump of the duodenum, including the intersection of the duodenum, closing its lumen by stitching, followed by suturing of the tissues of a nearby organ, characterized in that when crossing the duodenum, it is cut off from the stomach, and stitching is performed by applying a continuous through suture to the front and back walls duodenal stump and immersion under the sero-muscular purse string suture placed around the first suture by tightening it without sealing the first continuous through suture, after which the suturing of the tissues of the nearby organ, covered with the peritoneum, to the duodenal stump with nodular sero-muscular sutures, the threads of which are carried out under the string of the purse string suture, is performed.

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