Method for treating duodenum stump

FIELD: medicine.

SUBSTANCE: method involves evaginating duodenum stump with polypotomy loop into organ wall followed by electric surgical excision.

EFFECT: stable hemostasis; provided aseptic conditions in sealing the stump.

3 dwg 1 tbl

 

The invention relates to medicine, namely to surgery, and can be used in the treatment of patients who are gastric resection or gastrectomy.

There is a way to handle the stump of the duodenum in which the stump bandaging, shielding her sero-missionim purse string suture (method Finsterer) (Navrotsky I.N. Closure of the duodenal stump. M: Medicine. 1972. P.55-56).

However, with this method it is possible the development of insolvency seams stump duodenal ulcer caused by infection are “closed septic cavity between joints, the development of ischemia, followed by necrosis of tissue in the suture band due to their compression and deformation of the suture material.

The technical result consists in the creation of aseptic conditions during the sealing process, the elimination of the cavity between joints, minimum of injury and deformation fabrics in the field seam roller stump of the duodenum.

The essence is that in the processing method of the stump of the duodenum, including bandaging the stump and shelter her sero-muscular purse-string suture, the stump of the duodenum mainroot politano loop in the wall of the body, with subsequent electrosurgical cutting off.

The method is as follows.

After mobilise the AI of the stomach and duodenum in the volume of planned resection or gastrectomy, the stomach is cut off from the duodenum by Kocher clamp, under pre-fed pulpotomy loop. Tighten polidocanol loop and simultaneously remove the Kocher clamp. Next, the duodenal stump is held polidocanol loop. On the wall of the duodenum impose a purse-string serous-muscular suture (figure 1). When traction all threads purse string suture up is evaginate stump duodenal ulcer in the wall. Tighten the ends of the thread around the tip polidocanol loop, connect the active electrode electrocautery to the axial thrust polidocanol loop (figure 2). Moving the sliding carriage polidocanol loop up, produce clipping (amputation) Evgenievna in the intestine wall of the duodenal stump. Tightening the knot purse-string suture, remove the tip polidocanol loop from serosa-muscle suture (figure 3).

Testing method conducted in early on a human cadaver (12 cases). In these studies tested the most appropriate processing techniques stump duodenum, using the proposed method. In experimental studies in 17 dogs investigated the nature of the reparative process in the field sutured to the stump of the duodenum using the specified method. Positive results were obtained. Animals after mobilization of the stomach and duodenum in the amount of planiruet the Oh resection of the stomach was cut off from the duodenum by Kocher clamp, under pre-summed polidocanol loop. Tightening polidocanol loop, simultaneously shot a Kocher clamp. Next the stump of the duodenum kept polidocanol loop. On the wall of the duodenum imposed purse string suture. When traction all threads purse string suture up produced evaginate stump duodenal ulcer in the wall. Tightened the ends of the thread around the tip polidocanol loop was connected to the active electrode electrocautery to the axial thrust polidocanol loop. Moving the sliding carriage polidocanol loop up, made the cut (amputation) Evgenievna in the intestine wall of the duodenal stump. Tightening the knot purse-string suture, brought the tip polidocanol loops of serous-muscular suture.

Macro-microscopic research, and the study of biochemical and biophysical indicators allowed us to assess tissue homeostasis and the nature of the reparative process, thereby to determine the advantages of the proposed method of sealing the stump of the body. Installed quick regeneration of tissues in the stump. Intraoperative and early postoperative period is minimal disruption of the trophic tissue in the joints, which is registered by studies of the redox potential (redox sweat the capacity) in the tissues, captured by the suture, the intensity of free-radical reactions of lipid peroxidation (content in tissue structures seam of TBA-active products) and the activity of phospholipase A2(in tissue structures of the joint). In the control group (conventional tillage stump) in the early postoperative period (first three days) redox potential, the level of TBA-active products, the activity of phospholipase A2 were significantly higher (see table 1)than in the experimental group (a method). In the study of the biological forces of consolidation established that the developed method, it was sufficient and was not inferior to that in the double row suture.

Complications in the early postoperative period. In the study of the tissues in the area of operation after 30 days of pathological formations are not revealed. Marked recovery of ductility structures ulcer in the area of the wound.

Table 1 presents some biochemical and biophysical indicators regenerating structures stump duodenum, formed in different ways (M+m), where I is the control group (traditional method), II - experimental group (the proposed method), *certain significant differences compared with the outcome, bold reliably significant differences compared to control.

Table 1
IndexExodusgroupStages of postoperative observation day
13715
Redox potential, mV-35,23 1,02I-69,78 1,18*-56,14 1,23*-39,04±1,09-36,99±1,23
II-62,13±1,16*-45,27±1,18*-38,18±1,04-36,12±1,15
The content of TBA-active products, nmol/g protein3,44±0,12I5,98±0,32*4,89±0,21*3,96±0,263,55±0,36
IIbr4.61±0,21*4,11±0,24*3,68±0,193,62±0,33
The activity of phospholipase A2, µmol/g protein1,13±0,06I2,34±0,15*1,93±0,11*1,34±0,121,18±0,15
II1,72±0,13*1,39±0,09*1,27±0,171,21±0,16
The power of biological consolidation tissues, kPa I 16,02±1,9615,43±2,0825,45±2,1431,15±1,76
II15,12±2,0714,32±1,8126,11±1,8732,12±1,77

The method was successfully tested in 26 patients with peptic ulcer disease and gastric cancer in age from 29 to 78 years. The patients underwent gastrectomy (8) and gastrectomy (18).

When analyzing the immediate and long-term results in patients operated with the use of electrosurgical evagination-amputation bezlistovogo processing method stump of the duodenum with a period of observation of up to 15 years, a high efficiency in the way. In all cases there was a positive result. Insolvency seams stump, infiltration of tissues and abscesses in the area of mainali was not. Established rapid recovery of bowel function. All patients were discharged from hospital with recovery.

In the control group, consisting of 33 patients, the applied method of Finsterer or options for its modification. It turned out that in 4 cases there was a failure of the seams stump duodenum, causing peritonitis and death in 2 cases. 2 patients produced external drainage of the duodenum, which required prolonged conservative treatment. Fistula is acrylis yourself patients recovered.

Example. Patient R. (1939, N832) was admitted to the hospital for cancer of the antrum, complicated subcompensated stenosis of the output section of the stomach. From the anamnesis: sick peptic ulcer disease for 8 years. When endoscopic (with biopsy), x-ray studies revealed the ulcer cancer of the antral body diameter > 4 cm scar-ulcer deformation of the body, subcompensated stenosis. After preoperative preparation under General anesthesia the patient underwent laparotomy, gastrectomy. The stump of the body processed the specified electrosurgical aseptic way. In the early postoperative period there were no complications. After 13 days after the operation the patient was discharged in satisfactory condition. Observation for 6 years. Complications were found.

Thus, the proposed method allows to create optimal conditions for regenerating structures sutured to the stump of the duodenum, to eliminate a closed septic cavity, to prevent bleeding from the intramural vessels in the intestinal lumen, it provides maximum aseptic conditions during processing, the use of single-serous-muscular purse string suture helps to minimize disturbance of trophic tissue wall of the duodenum kick is in the area of vaginali stump.

The method of processing the stump of the duodenum, including bandaging the stump and shelter her sero-muscular purse-string suture, wherein the residual limb of the duodenum mainroot polidocanol loop in the wall of the body, with subsequent electrosurgical cutting off.



 

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