The method of treatment of gastroduodenal bleeding
The invention relates to medicine, surgery. Gradually perform hemostasis. Cut away the source of bleeding drugs. Consistently give the solution of tocopherol acetate and the solution atoxisklerol. Exercise endoskopicheskoe study. Spend intraoperative fibrogastroscopy with video-assisted laparascopic the clipping vessels of the stomach. Carry out chemical neuralis the lesser curvature of the stomach, pharmacological blockade of the hepato-duodenal ligament. Held hemostasis is used both independently and in stages. The method reduces the number of recurrences of bleeding. 1 Il.
The invention relates to medicine, namely to surgery, and can be used for the treatment of patients with peptic ulcer and non-ulcer gastroduodenal bleeding.
The urgency of the problem of endoscopic hemostasis with gastroduodenal ulcer bleeding due to high mortality after emergency operations, and is 5.7-35,2% (VV gorbashko A. I., 1980; Petrov, B. N. et al., 1987; Kuragin A. A. et al., 1992; Qvist P. et al., 1994).
A particular hazard recurrence of bleeding. Mortality in them increases to 30-40% (Lutsevich E. C. et al., 1991; Football already known methods and to look for new solutions to this problem. There are many endoscopic methods stop gastroduodenal bleeding. But none of the methods of endoscopic hemostasis does not guarantee against relapse of bleeding even in the hours after therapeutic endoscopy.
Known endoscopic treatment of gastroduodenal bleeding by laser photocoagulation, which consists in the fact that the bottom of the defect is covered with a film of coagulated blood, and the zone of coagulation necrosis extends into the submucosal layer of the stomach wall. In the muscular and serosal layers are observed inflammatory edema and stasis in small vessels (Galinger Y. M. et al. The prospect of applying laser radiation through the endoscope in the gastro-intestinal bleedings// 30 all-Union Congress of surgeons. Sat. the scientific. works. Minsk, 1983).
However, laser photocoagulation has its negative sides.
Thus, the number of recurrent bleeding after successful laser photocoagulation reaches 57%. In addition, there is the complexity of the dosage of radiation at the source of bleeding in connection with the fact that the blood is continuously flowing out of the vessel, has a scattering effect on the radiation, so either weakened himself coagulating effect, which is accompanied by deterioration of the I body. All this leads to low efficiency of primary hemostasis; a high percentage of recurrent bleeding; the complexity of the dosage of radiation at the source of bleeding; the possibility of increased bleeding due to evaporation of the vessel wall; a large number of complications, which consists in perforating the walls of the body, the emergence of extensive necrosis; long-term healing of ulcers after photocoagulation.
The closest achieved a positive result (the prototype) is a method of treatment of gastroduodenal bleeding by direction of the source of bleeding drugs, such as epinephrine 1:10000. The mechanism of hemostasis associated with mechanical compression of the vessel and vasoconstrictive effect that allows you to slow down or stop krovotechenie (Korotkevich, A. G., Perkin, E. M. Comparative evaluation of methods of endoscopic hemostasis with gastroduodenal ulcer bleeding// journal of surgery, 1998, T. 157, No. 2, S. 26-28).
However, the duration of the achieved hemostasis small because of fast resorption of the preparation used, due to which bleeding can resume.
The disadvantages of this method of treatment of gastroduodenal krovotechenia.ne effect; the increase in vascular resistance in the liver, with increased portal pressure, and therefore increases the risk of recurrent bleeding; high percentage of recurrence of bleeding when using this method reaches 30%.
The authors propose a combined method of treatment of gastroduodenal bleeding, including 2-stage in achieving hemostasis. A positive result of the proposed method is to increase the efficiency of treatment by achieving a stable hemostasis and reduce the risk of recurrent bleeding.
A positive result is achieved by the fact that you are doing around the source of bleeding in a 30% solution of tocopherol acetate in the amount of 5-6 ml and 0.5% solution of atoxisklerol 1-2 ml, followed by endoskopicheskoe study with intraoperative fibrogastroscopy, video-assisted laparascopic the clipping vessels of the stomach, chemical neurolysis the lesser curvature of the stomach and pharmacological blockade of the hepato-duodenal ligament.
A method of hemostasis at the gastroduodenal bleedings used in acute, chronic ulcers of the stomach and duodenum, bleeding after polypectomy, syndrome Mallory-Weiss.
The method is carried out ledue drugs (can be used simultaneously without the 2nd stage).
Sores around (locally) on 4 sectors in circumference injected with 1.5 ml of 30% solution of tocopherol acetate (vitamin E), (total number of 5-6 ml). Creates oil submucosal cushion, which mechanically compresses the vessels of the submucosa membrane. However, vitamin E as antioxidant and antihypoxic drug improves the processes of regeneration and promotes more rapid healing of the ulcer. To complete hemostasis in the area of the ulcer crater injected with 1-2 ml of 1% solution of atoxisklerol for stimulation aseptic inflammation in the ulcer crater and the coagulation adjacent to the bottom of the ulcer vessels.
Advantages held the 1st stage: duration of tocopherol acetate; local effect of the drug and the absence of absorption in the bloodstream; the improvement of the processes of regeneration in the plague; reducing the frequency of recurrent bleeding (12.5 percent when used alone the 1-St stage), reducing the number of emergency operations.
In patients with high risk of recurrence of bleeding in acute, chronic ulcers of the stomach and duodenum, the syndrome Mallory-Weiss as an additional hemostasis conduct the second phase, consisting in endoskopicheskim issledovatel stomach, chemical neurolysis the lesser curvature of the stomach and pharmacological blockade of the hepato-duodenal ligament.
the 2nd stage is conducted under General anesthesia (endotracheal anaesthesia) enter the trocars: 1 - 10 mm 2 cm above the umbilicus in the midline; 2nd - 10 mm at the intersection of the umbilical and adrectal lines; 3 - 5 mm in the left pogrebennoi region adrectal line; 4th - 5 mm in the midline epigastric. At the same time are fibrogastroscopy, which is displayed when the ulcer crater. Videolaparoscopic adjacent to the ulcer crater vessels are clipped. To reduce the spend acid drug vagotomy by chemical neuralize the lesser curvature of the stomach from the antrum to the esophagus. For this subserous enter 50-80 ml of 30% ethanol solution specially designed needle for laparoscopic medical neurolite (see drawing). The needle consists of working part - 1 length 5 mm, diameter 0.5-1 mm; case - 2, 20 cm long, inside which is placed a hollow nylon catheter - 3 with a diameter of 1-1,5 mm cannula - 4 (for connection of a syringe). In the hepato-duodenal ligament injected nylon catheter, which is fixed with a clip. The catheter is injected 10 ml of 0.5% solution of the t 30 minutes.
Benefits held by 2nd stage: it allows to achieve stable, long-term hemostasis; to reduce the risk of rebleeding: mimic neurosis reduces kislotoproduccia stomach in 1.5 times; procaine blockade hepato-duodenal ligament will reduce vascular spasm own hepatic artery and the hepatic vessels, this in turn causes reduced blood flow in the pool of gastric artery with redistribution to the liver; use endoskopicheskogo surgical intervention in the treatment of patients with gastroduodenal bleeding will allow to optimize the management of patients, to achieve adequate hemostasis in a short time, to reduce the number of emergency operations, postoperative complications and frequency of lethal outcomes in this challenging group of patients.
Clinical case 1
Patient D. 73 years of age, was treated in the urology Department of the Regional clinical hospital with 26.03.02 with a diagnosis of prostate adenoma 3 tbsp., the operation 3.12.01 - cystostomy. Chronic renal failure 2 degrees.
Coronary heart disease, angina 2 F. CL.
Patients received elective surgery 1.04.02 - bilateral Lazarescu, adenomectomy - 2-th stage.
In ostranenie tamponade bladder.
The patient is in serious condition was in the ICU.
In ARIT patient was carried out appropriate therapy, shimmered single-group erythrocyte mass.
16.04.02 in the ICU, the patient appeared evident weakness, dry mouth, vomiting color "coffee grounds", melena.
Urgently 16.04.02 the patient underwent fibrogastroscopy, when detected: mucosa of the esophagus erozirovanne, with a dirty-gray bloom, in the stomach a small amount of crimson clots. In the bulb of the duodenum old scars constricting the lumen to 1.5, see the posteromedial wall of the duodenal bulb flat ulcer 0,3-0,2 cm with thrombosed vessel at the bottom. Made hemostasis with epinephrine 1 ml per 10 ml of 0.9% saline solution. Conclusion: chronic duodenal ulcer, bleeding Unstable hemostasis. The state after the bleeding. Chronic duodenal ulcer, scarring. Cicatricial deformity of duodenal ulcer. Erosive esophagitis.
The patient has a nasogastric was conducted hemostatic therapy, single-group transfused red blood cells.
b-40 g/l, er - 1.6 (p. SP/mm cubic), lake 18.8 thousand (Tox. grain., pallet. bleeding - 8 min, platelet - 110 thousand/mm cubic, urea - 41,8 mmol/l, creatinine - 258.
17.04.02 - the patient by nasogastric probe blood and detachable color "coffee grounds", a one-time loss of consciousness.
Diagnosis: recurrent bleeding from a duodenal ulcer.
Urgently 17.04.02 the patient underwent fibrogastroscopy: duodenal bulb fresh blood clot at the bottom of the ulcer. the defect along the old transverse scar is increased by the square of 0.4-0.6 cm, with a yellowish tinge, blood clots at the bottom of the defect. Conducted hemostasis 30% solution of tocopherol acetate 5 ml, in combination with 1.5 ml of 1% solution of atoxisklerol by the above method (1 stage). Conclusion: chronic duodenal ulcer complicated by recurrent bleeding. Unstable hemostasis.
When the control fibrogastroscopy 18.04.02. Conclusion: chronic duodenal ulcer without evidence of bleeding. The bottom is made of grey fibrin. Sustainable hemostasis.
Patients received a course of conservative therapy.
Was discharged in good condition.
Diagnosis: prostate adenoma 3 degrees. Operation 1.04.02 bilateral Lazarescu, 2nd stage adenomectomy. Cystostomy. Chronic renal failure 2 degrees. Tamponade of the bladder from th bleeding 16.04.02, recurrence of bleeding 17.04.02. The heavy blood loss severity. Hemorrhagic shock 2 degrees. Posthemorrhagic anemia.
Hydrothorax on the left. Encysted pleurisy on the right. Coronary heart disease, angina 2 F. CL.
Clinical example 2
Patient A. 64 years, was admitted to the Department of surgical gastroenterology Regional clinical hospital by ambulance 20.11.01. with a diagnosis of chronic duodenal ulcer (DU), complicated by bleeding, hemorrhage moderate severity. Coronary heart disease, angina 2 F. CL., hypertension 3 tbsp., chronic obstructive bronchitis, remission.
Upon receipt 20.11.01 urgently made fibrogastroduodenoscopy, during which revealed: in the stomach a small amount of content color "coffee grounds" in the duodenal bulb on the lateral wall of moderately deep ulcer of 0.7-0.9 cm in diameter, a depth of 0.3 see At the bottom of ulcer hemorrhagic inclusion and gray patina. Rough cicatricial deformity of the duodenal bulb. Conclusion: chronic duodenal ulcer, scar deformity of the duodenal bulb. The state after the bleeding. High risk of rebleeding. Unstable hemostasis.
Tests for admission: HB-83 g/l, erythrocytes - 2,9 (p. SP./mm cubic), fibremetal high risk of rebleeding.
Operation in an emergency - 20.11.01 - endoskopicheskoe research ulcers. Laparoscopic clipping vessels, chemical neuralis the lesser curvature of the stomach. Catheterization hepatoduodenal bundles (duration 25 minutes).
In the postoperative period the patient received conservative treatment.
The catheter was introduced 0.5% solution of novocaine 4 times a day, for 5 days. The catheter is removed.
In the postoperative period without complications. Healing by first intention.
Fibrogastroduodenoscopy 27.11.01. - Reduction of the ulcer to 0.1 cm, the defect is equal to the level of the mucosa. The bottom is covered with fibrin.
The patient was discharged in satisfactory condition 28.11.01
Clinical case 3
Patient I. 34 years, was admitted by ambulance to the Department of surgical gastroenterology Regional clinical hospital 12.11.01 with complaints: weakness, Melun, dizziness, vomiting after drinking alcohol with blood once.
When receiving HB - 93 g/l, erythrocytes - 3,1 (p. SP/mm cubic), PETIT - 83%, APTT - 47 (44),; fibrin monomer complex - 12, platelet-255 (thousand mm cubic), leukocyte - 6,8 (thousand mm cubic).
Fibrogastroscopy 12.11.01. In the cardia on the front wall slit-like defects of 0.15-1.5 cm with fibrinous-hemorrhagic inclusions. Unstable hemostasis. PS. The state after the bleeding.
Diagnosis: syndrome Mallory-Weiss, stomach bleeding, Bleeding of medium severity. Posthemorrhagic anemia. The risk of recurrent bleeding.
The second stage, the patient underwent surgery 12.11.01 emergency procedure - laparoscopic hemostasis, under the control of fibrogastroscopy, chemical neuralis the lesser curvature of the stomach (medical vagotomy), catheterization hepato-duodenal ligament.
In the postoperative period without complications. Healing by primary intention. The sutures were removed. The catheter was introduced 0.5% novocaine 10 ml for 3 days - 4 times. The catheter is removed.
When the control fibrogastroscopy - 18.11.01 - epithelialization of the defect in the mucosa.
When the extract blood: HB - 103 g/l, erythrocytes - 3,4 (p. SP./mm cubic).
The patient was discharged in satisfactory condition.
Thus, the claimed method is used to stop bleeding, reduce the risk of rebleeding, to prepare the patient for a planned or deferred transactions or to conduct independent conservative treatment.
The method of treatment of gastroduodenal bleeding by direction of the source of bleeding dosage of prepl acetate in the amount of 5-6 ml and 0.5-1% solution of atoxisklerol in the amount of 1-2 ml, then spend endoskopicheskoe study, including intraoperative fibrogastroscopy in combination with video-assisted laparascopic the clipping vessels of the stomach, chemical neurolysis the lesser curvature of the stomach and pharmacological blockade of the hepato-duodenal ligament, and held hemostasis is used both independently and in stages, depending on the indications.
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