Method of procession of duodenal stump in case of ulcers penetrating into head of pancreas

FIELD: medicine.

SUBSTANCE: invention relates to medicine, abdominal surgery, and can be used in treatment of duodenum ulcers. Duodenum is exposed and dissected at the level of distal edge of ulcer. First row of sutures is applied between distal edge of ulcer and anterior wall of duodenum. Indenting from proximal edge of ulcer, cut 5-6 mm deep is made on contour of ulcer bottom, forming "peak" from healing tissue. Between "peak" and anterior wall of duodenum second row of sutures is applied with tamponade of ulcer bottom with anterior wall of duodenal stump. The third row of sutures is applied between healing tissues of pancreas and anterior wall of duodenum. Method allows to suture duodenal stump reliably and hermetically due to reduction of tension of duodenum anterior wall during suturing.

EFFECT: ensuring possibility to suture duodenal stump reliably and hermetically.

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The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of duodenal ulcer, penetrating into the head of the pancreas.

Selection and crossing duodenal ulcers, deformed scar-ulcerative process, the closure of its stump is the most difficult stage complete resection of stomach ulcers, posteromedial wall of the duodenum, penetrating into the head of the pancreas, because the presence of scar-ulcer substrate and colasuonno infiltrate significantly reduces the possibility of safe crossing and reliable suturing stump of the duodenum.

Widely known so-called "snail" Yudin (Navrotsky I.N. Closure of the duodenal stump. M.: Medicine, 1972, str-128). In this way the duodenal stump is sutured in the form of a cone, starting from the distal edge of the lesion, is folded in the shape of a snail at the bottom of the ulcer, campanera her. The stump additionally recorded seams at the edges of the ulcer and the capsule of the pancreas. The disadvantage of this method is that in the collapsed cone of the duodenal stump is disturbed intramural blood flow, using the seam of the capsule of the pancreas causing her trauma, which leads to inflammation ku is ti and surrounding tissues. In addition, this method is applicable in the absence of changes in the lateral wall of the duodenum.

Also known processing methods stump duodenum when penetrating ulcers, including the selection of the duodenum and subsequent shelter her stump (patent RU 2253381, IPC AV 17/00; patent RU 2238044, IPC AV 17/00; patent RU 2016548, IPC AV 17/00; patent RU 2268002, IPC AV 17/00; patent RU 2016548, IPC AV 17/00; patent RU 2028102, IPC AV 17/00). These processing methods stump does not provide reliability ulcers posteromedial wall of the duodenum, penetrating into the head of the pancreas, requiring a highly skilled surgeon.

The closest in technical essence is a way of niessen, including the selection and crossing of the duodenum, with the subsequent closure of the duodenal stump for penetrating duodenal ulcer (Navrotsky I.N. Closure of the duodenal stump. M: Medicine. 1972, p.72-75). In this method, the first row of stitches is applied between the front wall of the duodenum and the distal edge of the ulcer. The second row of stitches runs between the front wall of the duodenum and the proximal edge of the ulcer. Then, put the third row of stitches between the capsule of the pancreas. The disadvantage of this method is t is, because of the tension of the front wall of the duodenum with its deficiency is gapping stump duodenal ulcers, teething ligatures due to the looseness of the edges of ulcers. Grasping into the joint capsule of the pancreas can cause trauma to the development of pancreatitis.

The objective of the invention is to reduce the frequency of insolvency seams stump duodenum and, as a consequence, reduction of postoperative mortality.

The technical result is to increase the reliability of the sealing stump duodenal ulcers by reducing tension on the anterior wall of the duodenum when applying suture rows.

The problem is solved in that in the known method of processing stump duodenal ulcers, penetrating into the head of the pancreas, including the selection and crossing the duodenum and subsequent closure of the stump, in which the first row of stitches put between the distal edge of the ulcer and the front wall of the duodenum, after crossing the duodenum at the level of the distal edge of the lesion and apply the first of a number of nodal joints, the second row of stitches put between the front wall of the duodenum and "visor" of scar tissue that form way is the incision depth of 5-6 mm on the upper contour of the bottom of the ulcer, some distance from the proximal edge of the lesion 5-6 mm, and the third row impose seams between robovie tissues of the pancreas and the anterior wall of the duodenum.

Processing stump duodenal ulcers, penetrating into the head of the pancreas, as follows. Produce the mobilization of the stomach within the resection. The duodenum crosses at the level of the distal edge penetrating into the head of the pancreas ulcers. Overlaps the first row of nodal joints between the distal edge of the ulcer and the front wall of the duodenum, with ligatures are made through the entire thickness of the bowel wall. Some distance from the proximal edge of the lesion 5-6 mm, the upper semicircle of the bottom of the ulcer edge slit, penetrating to a depth of 5-6 mm scar tissue, and form a kind of "cap" of scar tissue. Between formed in this way "visor", which partially restores missing here back wall of the duodenum, and the front wall of the intestine overlaps the second row of nodal joints with tamponade of the bottom of the ulcer is the anterior wall of the duodenal stump. The stump of the duodenum was additionally fortified interrupted sutures placed between robovie tissues of the pancreas and anterior stink the second duodenum. Kind of a "visor" from scar-sclerotioides of pancreatic tissue, formed by the incision as described above, allows the use of fewer tissues of the anterior wall of the duodenum excludes the teething ligatures second row of stitches. Some mobility "visor" towards shivaami stump allows you to use fewer tissues of the anterior wall of the duodenum by plugging the bottom of the ulcer, and this reduces the tension on the seams, and it preserves the blood supply to the stump, is conducive to the rapid fusion of the anterior wall with the bottom of the ulcer and prevents necrosis.

The inventive method is illustrated by a drawing operation, in which figure 1 is a frontal section presents nausithoe the duodenal stump and the surrounding tissue drawn through the plague and the head of the pancreas; figure 2 is a frontal section of the duodenal stump, sutured the first row of stitches, and cut along the upper contour of the bottom of the ulcer with the formation of the "visor" from scar-scleratinian tissues of the pancreas; figure 3 is a frontal section of the duodenal stump, second-row stitched seams; figure 4 is a frontal incision sutured duodenal stump in the final version.

Example 1

Patient E., 34, and/b No. 7973, the diagnosis of peptic Ulcer disease dwenadzatiperstnuu the second colon, complicated by penetration in the head of the pancreas, hepato-duodenal ligament and subcompensated stenosis. Complaints of pain in the epigastric region, growing 2-3 hours after a meal, nausea, occasional vomiting. Ill for 7 years. Treated annually, with no improvement. During FGDs revealed duodenal ulcer 0,5-0,6 see After preoperative preparation, 8 days, resection3/4stomach in Vitebsk. During the operation expressed preprocess around the duodenum. On the front wall of her rough scar. The ulcer is located on the rear wall of the duodenum, penetrare in the head of the pancreas and hepato-duodenal ligament. The stomach is large. Mobilization of the stomach, duodenum crossed on the upper edge of the bottom of the ulcer. Ulcer 1.5×1.0 cm whitish, dense. Treatment of duodenal stump produced by the claimed method. Resection3/4stomach with superimposed transverse anastomosis with a short loop of jejunum in Vitebsk. The postoperative period is smooth. Was discharged in good condition.

Example 2

Patient R., 38 years old, and a/b No. 3467, the diagnosis of peptic Ulcer disease duodenal ulcer complicated by penetration in the head of the pancreas and decomp nirvanam stenosis. Complaints of epigastric pain, nausea, vomiting. Ill for 10 years. Lost 10 kg Conservative treatment brings temporary relief. After preoperative preparation operation performed resection3/4stomach in Vitebsk. Verkhnesadinsky laparotomy, stomach, large size, watery swelling of the walls and moderate varicose veins. In the field of duodenal tumor is palpated education penetrating into the head of the pancreas ulcer. With the technical difficulties of adhesions selected duodenum, crossed below the level of the stenosis. On the back wall of the duodenum ulcer with dense whitish edges and bottom, 1.5×1,5 see the Stump of the duodenum treated the claimed method. Gastrojejunostomy in Vitebsk. Marked increased bleeding during the operation. The postoperative period is smooth. Discharged on the 12th postoperative day in good condition.

Example 3

The patient, aged 39, and a/b No. 7557, the diagnosis of peptic Ulcer disease duodenal ulcer complicated by penetration in the head of the pancreas and decompensated stenosis. Complaints about persistent epigastric pain, worse after 1.5-2 hours after a meal, nausea, vomiting after meals, bringing relief to the loss in weight up to 12 kg, weakness, irritability. Surveyed. After preoperative preparation operation - resection3/4stomach in Vitebsk. In operation, the stomach is a thick-walled, large size. The bulb of the duodenum deformed by scars and spikes. The duodenum narrowed to 0.6 see the mobilization and the intersection of the front wall of the duodenum below the scars on the back wall ulcer 2,5×2.5 cm, the bottom and edges of dense, deep penetrare in the head of the pancreas. Treatment of duodenal stump claimed process. Resection3/4stomach. Gastrojejunostomy in Vitebsk on a short loop. The postoperative period is smooth. Discharged on day 13 after surgery in satisfactory condition.

Six months after surgery, the patient's condition is satisfactory, no complaints, normalized sleep and appetite, gained weight 5 kg

Using the proposed method operated on 60 patients who had duodenal ulcer, penetrating into the head of the pancreas. The inventive method is effective for the treatment of large ulcers posteromedial wall of the duodenum, penetrating into the head of the pancreas, especially when combined complications such as stenosis and bleeding. Cases nesostoyatelen the STI joints stump of the duodenum was observed. In all patients, the results of treatment should recognize the good.

The method is simple in technical execution, spent less time on the closure of the duodenal stump, its application does not require the highest skill of the surgeon, can be used in both elective and emergency surgery.

The method of processing stump duodenal ulcers, penetrating into the head of the pancreas, including the selection and crossing the duodenum and subsequent closure of the stump, in which the first row of stitches put between the distal edge of the ulcer and the front wall of the duodenum, characterized in that after crossing the duodenum at the level of the distal edge of the lesion and apply the first of a number of nodal joints of the second row of stitches put between the front wall of the duodenum and "visor" of scar tissue that form the incision depth of 5-6 mm along the contour of the bottom of the ulcer, some distance from the proximal edge of the lesion, with tamponade bottom of the ulcer front the wall of the duodenal stump, and third row impose seams between robovie tissues of the pancreas and the anterior wall of the duodenum.



 

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