Method for detecting the degree of acute anastomositis of gastroduodenal anastomoses

FIELD: medicine, diagnostics.

SUBSTANCE: it is necessary to evaluate the degree of gastroduodenoanastomosis inflammation after operation in case of its endoscopic type of investigation due to visual evaluation of mucosal surface and the state of sutures in anastomosis area, and carrying out endoscopic ultrasonography of gastroduodenoanastomosis area. Moreover, one should detect the criteria of lesion depth in anastomosis wall by layers and the structure of detected altered part due to successive investigation of all layers of gastric wall, duodenum and adjacent tissues in anastomosis area. In case of signs of growing inflammatory infiltration onto mucosa only at thickening of mucous layer and edema of basement membrane depending upon the degree of edema one should diagnose finishing epithelization of anastomosis area in case of inconsiderably pronounced edema, and at a 2-fold thickening of this mucosal layer as a result of edema - catarrhal (surface) anastomositis. At detecting the growth of inflammatory infiltration onto both mucous and submucous layers at availability of surface defect being not deeper than basement mucous membrane along with thickened mucous and submucous layers and availability of small point or linear hyperechogenic inclusions in mucous and submucous layers one should diagnose catarrhal-erosive anastomositis. At the growth of inflammatory infiltration onto mucous, submucous and muscular layers, impossibility for distinct detection of the borders between these layers, disorders in architectonics of muscular layer one should diagnose infiltrative anastomositis. At addition of ultrasound signs of erosion to the above-mentioned picture in the form of small points or linear hyperechogenic inclusions in mucous and submucous layer, widened vessels in submucous layer and indistinct borders between these layers it is possible to diagnose infiltrative-erosive anastomositis. In case of destroyed integrity of mucous and submucous layers at involvement of muscular membrane as hypoechogenic part of destruction, in the bottom of which one should observe hyperechogenic necrotic masses, development of inflammatory infiltration onto mucous, submucous and muscular layers at affected architectonics of muscular layer and absence of distinct borders between the layers in area of defect one should detect destructive anastomositis. In case of affected integrity of mucous, submucous and muscular layers as hypoechogenic part of destruction at hyperechogenic necrotic masses and availability of defect for the whole thickness of the wall in area of gastroduodenoanastomosis, development of inflammatory infiltration for all layers of anastomosis at developing anastomosis' infiltrate and, also, periprocesses, abscesses associated with the line of anastomosis sutures and beyond external wall of gastroduodenoanastomosis one should diagnose destructive anastomositis complicated with failed anastomosis. The innovation is of high information value, requires no contrast preparations and enables to study layer-by-layer structure of wall in area of gastroduodenoanastomosis. This innovation is very useful to be applied in early postoperational period.

EFFECT: higher accuracy and reliability of detection.

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The invention relates to the field of medicine, diagnosis, particularly to a method of determining the degree of acute anastomotic gastroduodenal anastomosis.

Known methods of determining the degree of anastomotic gastroduodenostomy in the postoperative period after resection of the stomach Billroth-I by endoscopic and morphological studies [1, 2].

Closest to the proposed method is a method of determining the degree of acute anastomotic gastroduodenal anastomosis,consisting in the endoscopy area of the anastomosis and the visual determination of the degree of acute anastomotic on endoscopic picture [3].

However, this diagnostic method is not highly accurate and informative, as it is subjective, it is possible to evaluate only the mucosal surface of the investigated area of the gastroduodenal junction, there are no data on the structure of all layers of the wall of the stump of the stomach and duodenum in this area, and others formed the anastomosis tissue. The ability to obtain the metric characteristics of the structures, especially when it comes to the measurement of relatively small elements, delimited by esophagogastroduodenoscopy (FGDS), the more General it is not possible to remove the metric characteristics of the layers of the wall of the issled the constituent body and located deeper abnormal areas beyond the coverage of the surface by endoscopy, there is no morphological criteria for evaluating the severity of lesions of the wall of the stump of the stomach and duodenum in the anastomosis. Because of the limitations of the research method during FGDS really was not evaluated extraordinai complications in the postoperative period in the anastomosis in the form of Sadekov and postoperative edema structural elements gastroduodenostomy, requires revision assessment of regional blood flow is formed in the region of the anastomosis and directly the structures of the layers.

The problem solved by this invention is to improve the accuracy and usefulness of the diagnostic method.

A new technical result is an increase in the information content, accuracy of diagnosis is reached by applying a new method of determining the degree of acute anastomotic gastroduodenal anastomosis, which consists in assessing the degree of inflammation gastroduodenostomy after endoscopic surgery for his research, including a visual assessment of the mucosal surface and soundness of welds in the anastomosis, and additionally provide endoscopic ultrasonography zone gastroduodenostomy with the criteria of the depth of the destruction of the wall of the anastomosis in layers and patterns identified modified area by p is coherent research all layers of the stomach wall, duodenal ulcer and surrounding tissue at the anastomosis and if there is evidence of spread of the inflammatory infiltration only in the mucous membrane with the presence of thickening of the mucosal layer with edema of the basal membrane, depending on the severity of the edema is diagnosed with slightly pronounced edema ending epithelization the area of anastomosis, and in the thickening of this layer of the mucosa due to the swelling in 2 times - catarrhal (surface) anastomosis, when determining the distribution of inflammatory infiltration at the mucosal and submucosal layers with the presence of surface defect is not deeper than the basal membrane of the mucosa, thickening of the mucosal and submucosal layers, the presence of small point or linear hyperechoic inclusions in mucous and the submucosal layer, diagnose catarrhal-erosive anastomosis, the spread of the inflammatory infiltration at the mucosal, submucosal and muscular layers, the impossibility of a clear definition of the boundaries between these layers, the violation of architectonics muscle layer diagnosed infiltrative anastomosis, in addition to the above picture of the ultrasound signs of erosion in the form of a small dot or linear hyperechoic inclusions in the mucosal and submucosal layer, dilated blood vessels in the submucosal layer and neced the x boundaries between these layers, diagnose inflammatory-erosive anastomosis, in violation of the integrity of the mucosal and submucosal layers involving muscle membrane in the form of hypoechoic area destruction, the bottom of which is defined hyperechoic necrotic mass, the distribution of inflammatory infiltration at the mucosal, submucosal, muscle layers, with violation of the architectonics of the muscle layer and the absence of clear boundaries between the layers in the area of the defect is diagnosed destructive anastomosis, in violation of the integrity of the mucosal, submucosal and muscle layers in the form of a hypoechoic area of destruction with hyperechoic necrotic masses and the presence of a defect on the entire wall thickness in the area of gastroduodenostomy, the spread of the inflammatory infiltration of all layers of the anastomosis with formation of infiltration anastomosis and preprocess, abscesses associated with the line of stitches anastomosis and the outer wall of gastroduodenostomy, diagnose destructive anastomotic complicated by the failure of the anastomosis.

The method is as follows.

The patient according to the standard procedure performed endoscopic examination of the upper parts of the gastrointestinal tract (esophagogastroduodenoscopy) with the definition of the criteria of viability formed gastroduodenal is omosa, which includes a visual assessment of the severity of inflammation of gastroduodenostomy after surgery on the severity of hyperemia surface of the mucosa, edema, hemorrhages, erosions, ulcers, wall defects (worth seams) in the area of the gastroduodenal junction. Additionally provide endoscopic ultrasonography of the esophagus, stomach and duodenum by standard methods of evaluation of these sections of the gastro-intestinal tract [3].

Echoendoscope is fibroindex length 140-160 cm working length 105-125 cm) with side optics. The study was conducted according to the standard principles of this method of ultrasonic diagnosis [3]. When endoscopic ultrasound gastronomii patients after distal or Subtotal gastrectomy for Billroth-I with the formation of gastroduodenostomy end-to-end use of endoscopic ultrasound center to Change EU-M30 system EVIS video centre, EXPA Olympus CV-160, duodenoileostomy EVIS of EXERA OLYMPUS TJF Model 160R Series, ultra-thin ultrasonic sensors 12 and 20 MHz.

The study was conducted in the morning, on an empty stomach after an overnight fast. Premedication 30 minutes prior research includes intramuscular injection of 2 ml of 0.5% solution of seduksen, subcutaneous injection of 1 ml of 0.1% solution of atropine and subsequent anest is the Zia pharynx local anastatica (10% lidocaine solution), enter drug that suppresses the motility of the digestive tract (1 mg of glucagon).

The performance of endoscopic ultrasonography begin the methodology of standard esophagogastroduodenoscopy in position patient on left side. Subsequently, if necessary, the patient is placed on his back.

Absolute contraindication to the study is the refusal of a patient from this manipulation. Relative contraindications are the same as in esophagogastroduodenoscopy: large goiter, deformity of the cervical-thoracic spine, pronounced kyphosis (scoliosis, lordosis), the rigidity of the throat, narrowing of the esophagus (stomach), diverticula of the esophagus.

The introduction of fibergastroscope produce under visual control.

Echoendoscope injected into the stomach, and gently pushed into the distal duodenum, where it starts scanning. Further endoscopic agostiniana goes on gastroduodenostomy and the stump of the resected stomach. Scanning is produced perpendicular to the axis of the endoscope, that is, transverse and oblique ultrasonic sections of the gastro-intestinal tube.

Endoscopic ultrasonography gastroduodenostomy after distal gastrectomy for Billroth-I hold one of the options using the ultra high frequency of mitchiko is (12 and 20 MHz), inserted through a biopsy channel of a standard endoscope: 1) by direct contact of the sensor with the mucous membrane of the stomach and duodenum, 2) via filled with distilled water balloon covering the sensor, to improve the resulting image of the wall of the digestive tract, 3) after insertion through the instrument channel of fibergastroscope 40-100 ml of deaerated water into the lumen of the gastric stump. The duration of the examination is 15-20 minutes.

To study gastroduodenostomy use the image in the standard position. Standard position of endoscopic ultrasonography for the study of various organs have been proposed and described in detail in 1982 .Sivak, W.Strohm and M.Classen and approved by the International conference on endoscopic ultrasound, held in Stockholm in the same year. When evaluating gastroduodenostomy image is used in the transition from 3 to 4 standard [4]. The topography of the standard 3 and 4 positions after gastrectomy is changing as a result of entering into the area of resection as duodenal and antral.

For the study of gastrointestinal anastomosis use the image in the standard position at the level of the suture anastomosis. Get the layered image of the walls of the gastrointestinal tract.

azizia 3: the bulb of the duodenum. When the offset echoendoscope in onion scanning plane is changed from horizontal to sagittal. After resection of the stomach Billroth-I bulb of the duodenum is in the area of resection and the reference point at position 3 after the operation will duodenum immediately after gastroduodenostomy.

Position 4: antrum. After resection of the stomach is distal stump of the stomach. Bending and twisting the end of echoendoscope Department directly before gastroduodenostomy, you can get the most informative sections.

Ultrasonography of gastroduodenostomy operate in two modes: grayscale - In-mode and color Doppler scan.

The most important anatomical landmarks during endoscopic ultrasound are the gall bladder, the splenic vein, the aorta, the lower Vena cava. Individual anatomical and topographical relationships between the stomach and adjacent organs in each patient require the acoustic window in the optimum position.

Make a visual assessment of the structure of the distal stump of the stomach, gastroduodenostomy and the first segment of the duodenum (duodenal) immediately after the anastomosis in layers, removed the metric characteristics of the investigated structures are evaluated cravens the haunted vessels, surrounding gastroduodenostomy tissue. During the evaluation take into account elements such as the clarity and smoothness of the contours of each layer of the wall of the stomach stump, gastroduodenostomy, duodenum, completeness layers all over, the uniformity of their thickness, uniformity in echogenicity, presence or absence of defects, additional inclusions in the wall of the investigated area and beyond.

The wall thickness of the gastric stump and the first segment of the duodenum at the level of gastroduodenostomy with endoscopic sonography in normal varies from 4 to 5 mm. Sensitive technique ultrasound using ultra high frequency sensors up to 20 MHz is to receive ultrasonic shear walls of the body of the 9 layers and adjacent tissues practically relevant macroscopic histological slice emitting muscle layers always as hypoechoic structures, other connective tissue elements as layers of high density varying degrees of intensity.

Known clinical and endoscopic classification of acute anastomosis after resection of the stomach [3].

1. Ending epithelization of the area of anastomosis. Endoscopic picture is characterized by a holistic mucous membrane along the line of anastomosis, of whom noticed a slight swelling and infiltration of the submucosal layer. The mucous membrane of the stomach stump and gastrointestinal anastomosis are not visually different.

2. Uncomplicated anastomosis.

2.1. catarrhal (surface) anastomosis. On the mucous membrane anastomoticheskih rings moderate edema and hyperemia of the mucous membrane with petechial hemorrhages.

2.2. If the anastomosis of single erosions of small diameter anastomotic referred to as catarrhal-erosive.

3. Anastomosis with subclinical manifestations.

3.1. Infiltrative anastomosis. The mouth of the anastomosis looks dramatically swollen, hyperemic, covered with fibrin and thick viscous mucus. The lumen of the anastomosis narrowed, contact bleeding, often for apparatus impassable or go with the forcing. In the cult of the stomach is visualized picture of the violation of the evacuation in the presence of muddy, stagnant fluid mixed with food residue, adopted the day before.

3.2. When rendering surface or single drain erosion anastomotic referred to as inflammatory-erosive.

3.3. Destructive anastomosis is diagnosed when on a background of sharply infiltrated the mucous membrane in the area of the fistula is defined foci of necrosis irregular shape, covered with fibrin, merging multiple erosion and acute ulcers of various sizes, emerging preliator what's granuloma of irregular shape with purulent fibrinous plaque. Permeability for the endoscope can be saved, or accelerating.

4. Complicated acute anastomotic.

4.1. Anastomotic complicated by obstruction of the anastomosis. The stump of the stomach to the large size due to pererasseyaniya on an empty stomach contains a large amount of muddy stagnant greenish liquid mixed with food debris. After installation, nasogastric tubes, evacuation of stagnant gastric contents, wash the stomach stump on anastomotic ring visible picture expressed or infiltrative destructive anastomosis. The lumen of the anastomosis sharply narrowed, impassable for an endoscope. Its diameter may be reduced to 0,6-0,7 see

4.2. Anastomotic complicated by bleeding. It is observed from the drain of acute erosions and ulcers of the suture line, attachaudio necrotic foci invaginating wall of the first row of stitches fistula. Bleeding may have a different intensity in the form of a jet of blood or continuous drip of leaking blood, stopping bleeding with a fixed fresh, loose or leached by a blood clot.

4.3. Anastomotic complicated by the failure of the anastomosis. With progressive destructive anastomotic characterized by the presence of abdominal abscess associated with the line of stitches. In other situations it occurs the wedge is some of peritonitis due to leakage (messagevine, ischemia) seams fistula.

Analyzing the classification of the anastomosis with regard to opportunities and problems to be solved by the method of ultrasonography, should be complicated acute anastomotic obstruction and anastomotic bleeding to exclude from ultrasonographic classification of acute anastomosis after resection of the stomach. Signs of obstruction and bleeding at the anastomosis will be directly identified at endoscopy in this zone, plus they are the complications directly (as indicated in the classification) is designated expressed infiltrative and destructive anastomosis.

Based on the above, the applicants propose the following working classification of acute anastomosis after resection of the stomach for a method of endoscopic ultrasonography:

1. Ending epithelization of the area of anastomosis.

2. Uncomplicated anastomosis.

2.1. catarrhal (surface) anastomosis.

2.2. catarrhal-erosive anastomosis.

3. Anastomosis with subclinical manifestations.

3.1. infiltrative anastomosis.

3.2. inflammatory-erosive anastomosis.

3.3. Destructive anastomosis.

4. Complicated acute anastomotic.

4.1. Anastomotic complicated by the failure of the anastomosis.

Endoscopic examination gastroduodenal is comosa is the leading diagnostic method in the evaluation of the surface mucosa, while ultrasonography as such allows to carry out an objective investigation of all the layers of the stomach wall, to shoot with high accuracy in a static frame of interest measurement. The combination of these two highly informative technologies allows to reliably estimate all the structural elements of the wall gastroduodenostomy and parametreleri space.

Proposed criteria method for determining the degree of acute anastomotic gastroduodenal anastomosis using the proposed method research gastroduodenostomy obtained on the basis of inspection of the 59 patients who underwent distal gastrectomy for Billroth-I with the creation of gastroduodenostomy end-to-end.

Specific examples of the complete method.

Example 1. Patient S., 49 years. Case history No. 1071. Operation 16.07.2001, ulcer type II, continuously recidiviruyuschee for. Operations: ulcer in the posterior wall of the duodenal bulb 7 mm in diameter. Resection 1/2 stomach Billroth-I.

The postoperative course smooth.

On the 8th day after the operation (23.07.2001) made by FGDS and research according to the proposed method. The study was conducted in the morning on an empty stomach after an overnight fast. Premedication for 30 minutes before the study included intramuscular injection of 2 ml of 0.5% solution of seduksen, subcutaneous in the introduction of 1 ml of 0.1% solution of atropine and subsequent anesthesia of the pharynx local anastatica (10% lidocaine).

Endoscopic examination of the stomach and gastroduodenal junction: is a moderately severe redness, swelling in the area of gastroduodenal connections, defects no mucous. When inflating the anastomosis discovered free pass for the tube of the gastroscope. Conclusion: the Status after resection of the stomach Billroth-I. Endoscopic picture catarrhal anastomotic gastroduodenostomy.

In the study the proposed method was established that when evaluating patterns of gastroduodenostomy layers inflammatory infiltration in the area of the anastomosis applies only to the mucous membrane. Is determined by the thickening of the mucosal layer with edema of the basal membrane in 2 times.

Conclusion: the Status after resection of the stomach Billroth-I. Catarrhal anastomotic gastrointestinal anastomosis (Figure 1).

In this clinical example, confirmed the ability to reliably determine the severity of anastomotic gastroduodenostomy after resection of the stomach Billroth-I as at endoscopic examination and endoscopic ultrasonography.

Example 2. Patient K., 37 years. Case history No. 1436. Surgery resection 1/2 of the stomach by way Billroth-I. 19.01.2002, ulcer duodenal ulcer type II. Operations ulcer 10×7 mm PE Edna wall of the duodenal bulb.

The postoperative period was uneventful.

On the 6th day after the operation 25.01.2002 was done esophagogastroduodenoscopy. At endoscopic examination in the area of gastroduodenostomy resected gastric determined by marked swelling, redness of the mucous. There is a plaque of fibrin 0.9 cm on the front of the semicircle of the connection. The anastomosis is closed, go through the endoscope with little effort.

Conclusion: the Status after resection of the stomach Billroth-I. Erosive or ulcerative anastomotic gastroduodenostomy.

25.01.2002, the study was performed according to the proposed method. The study has found that the inflammatory infiltration in the area of gastroduodenostomy apply to mucosal and submucosal layers with uniform thickening, presence of surface defect of mucous is not deeper than the basal membrane of the mucosa and the presence of hyperechoic inclusions in the submucosal layer of the fuzzy boundaries between these layers.

Conclusion: Erosive anastomotic gastro-duodenal anastomosis after resection of the stomach Billroth-I (Figure 2).

Additional criteria endoscopic ultrasonography has allowed to draw a clear differential diagnosis between destructive and erosive-ulcerative and erosive anastomosis gastro is adenoacanthomas. Visual credible check endoscopic ultrasonography distribution of lesions on the mucosal and submucosal layers with only surface defects without engaging in destructive lesion of the muscular layer was allowed to assert that the patient erosive anastomosis.

Example 3. Patient N., 48 years. Case history No. 3480. Operation 18.05.2003, resection of 2/3 of the stomach Billroth-I about stomach ulcers I type. Operations in the lower third of the body of the stomach along the greater curvature has ulcer size 2×1.3 cm, bottom shtrobirovaniya vessels.

The postoperative period was uneventful.

On the 6th day after the operation 24.05.2003, esophagogastroduodenoscopy. During endoscopic examination in the area of the anastomosis are defined severe redness, swelling, the lumen his narrowed, mucous contact bleeding, mucosal defects no. When inflating the anastomosis is opened, the tube of the gastroscope passes with little effort.

Conclusion: the State after distal gastrectomy by way Billroth-I. Catarrhal anastomotic gastro-duodenal anastomosis (Fig.7).

24.05.2003, the study was performed according to the proposed method. The study has found that inflammatory infiltration apply to mucosal, submucosal and muscular the layers violation of architectonics muscle layer and the inability to determine the boundaries between these layers.

Conclusion: Infiltrative anastomotic gastrointestinal anastomosis after resection of the stomach Billroth-I (Figure 3).

In this clinical example demonstrates the ability to more reliably determine the severity of the inflammatory process in the field of gastroduodenostomy after surgery gastrectomy with additional criteria for the severity distribution of edema and infiltration by the layers of the wall of the stump of the stomach and duodenum during endoscopic ultrasonography, resulting in registered infiltrative anastomosis, although endoscopic examination was interpreted pathology as catarrhal anastomotic gastroduodenostomy, as this method of examination is impossible to assess the muscular layer of the wall of the gastro-intestinal tube in the anastomosis.

Example 4. Patient K., 37 years. Case history No. 1436. Surgery resection 1/2 of the stomach by way Billroth-I. 19.01.2002, ulcer duodenal ulcer type II. Operations ulcer 10×7 mm anterior wall of the duodenal bulb.

The postoperative period was uneventful.

On the 6th day after the operation 25.01.2002 was done esophagogastroduodenoscopy. At endoscopic examination in the area of gastroduodenostomy resected glucopyranoside pronounced swelling, hyperemia of the mucous. There is a plaque of fibrin 0.9 cm on the front of the semicircle of the connection. The anastomosis is closed, go through the endoscope with little effort.

Conclusion: the Status after resection of the stomach Billroth-I. Destructive anastomosis (erosive-ulcerative) gastroduodenostomy.

25.01.2002, the study was performed according to the proposed method. The study has found that the inflammatory infiltration in the area of gastroduodenostomy apply to mucosal, submucosal and muscle layers with uniform thickening, it is impossible to clearly define the boundaries between the layers. Broken architectonics muscle layer. In the mucosal and submucosal layers are determined by the surface defects in the form of a small point and linear hyperechoic inclusions is not deeper than the basal membrane of the mucosa.

Conclusion: Infiltrative-erosive anastomotic gastro-duodenal anastomosis after resection of the stomach Billroth-I (Figure 4).

Thus, the proposed method has allowed to draw a clear differential diagnosis between destructive and infiltrative forms of acute anastomotic gastroduodenal anastomosis. Plaque of fibrin during endoscopy allowed to suspect destructive anastomosis, but ultrasonic evaluation walls ANAS is omosa layers was diagnosed with infiltrative erosive anastomosis. Tactical management of patients with this pathology differ in therapeutic and surgical approach.

Example 5. Patient K., aged 57. Case history No. 4053. Surgery: distal gastrectomy by Billroth-I 26.12.2002, ulcer type II, complicated subcompensated stenosis pylorobulbar zone. Operations identified cicatricial deformity of the duodenal bulb with clearance of not more than 5 mm.

The postoperative period was uneventful.

On the 11th day after the operation 06.01.2003, esophagogastroduodenoscopy. During endoscopic examination in the area of the anastomosis are defined severe redness, swelling, the lumen his narrowed, mucous contact bleeding, on the back of the semicircle anastomosis has a mucosal defect size of 0.5 cm, covered with fibrin. When inflating the anastomosis is opened, the tube of the gastroscope passes with little effort.

Conclusion: the Status after resection of the stomach Billroth-I. Destructive (erosive-ulcerative) anastomotic gastro-duodenal anastomosis.

06.01.2003, the study was performed according to the proposed method. The study has found that violated the integrity of the mucosal and submucosal layers involving muscle membrane in the form of hypoechoic area destruction, the bottom of which ODA the process identifies hyperechoic necrotic mass, inflammatory infiltration apply to mucosal, submucosal, muscle layers violation of architectonics muscle layer and the boundaries between layers.

Conclusion: the Status after resection of the stomach Billroth-I. Destructive (ulcerative) anastomotic gastro-duodenal anastomosis (Figure 5).

This clinical case helped on the basis of application of the proposed method, including the definition of ultrasonographic criteria, more precisely registrierung the severity of anastomotic gastroduodenostomy - destructive anastomosis, in the anastomosis discovered the plague. At endoscopy was also determined destructive form of anastomosis, but under the area of mucous membrane covered with fibrin was supposed to be possible as the ulcer and erosive surface, and this form was interpreted as destructive anastomosis - erosive-ulcerative.

Example 6. Patient 3., 52. Case history No. 1886. Operation 14.11.2002, Distal resection of 2/3 of the stomach by way Billroth-I about giant ulcers of the gastric body. When the operation on the rear wall of the lower third of the body of stomach ulcer size 40×20 mm with a pronounced inflammatory infiltration of the stomach wall.

The postoperative period was complicated by subphrenic abscess on the left.

On the 12th day after surgery, 26.1.2002 made esophagogastroduodenoscopy. During endoscopic examination in the area of the anastomosis are defined severe redness, swelling in the area of gastroduodenostomy lumen is narrowed his, mucous contact bleeding. On the back of the semicircle anastomosis has a mucosal defect size 7 mm, covered with fibrin. When inflating the anastomosis is opened, the tube of the gastroscope passes with little effort.

Conclusion: the Status after resection of the stomach Billroth-I. Erosive or ulcerative anastomotic gastro-duodenal anastomosis.

26.11.2002, a study was conducted according to the proposed method. The study has found that violated the integrity of the mucosal and submucosal layers, and the muscle membrane in the form of hypoechoic plot destruction with hyperechoic necrotic masses and distribution of inflammatory infiltration of all layers of the anastomosis with formation of infiltration anastomosis, preprocess as hypoechoic swelling of the structures on the outside wall of the stomach, abscess 25×15 mm in the form of a hydrophilic area of the spherical form with an irregular outer boundary associated with the line of suture anastomosis.

Conclusion: the Status after resection of the stomach Billroth-I. Complicated ulcer perforating) anastomotic gastro-duodenal anastomosis, insolvency is alnost anastomosis (6).

This example proves the possibility on the basis of the evaluation of all structures wall gastroduodenostomy layers with endoscopic ultrasonography to diagnose more accurately and correctly specific form of anastomosis. In the given example is diagnosed complicated by the inconsistency degree (ulcerative-perforating) anastomotic gastroduodenostomy, during its evaluation during esophagogastroduodenoscopy as destructive uncomplicated (erosive-ulcerative) anastomosis.

These clinical examples illustrate the possibilities of the proposed method to objectively assess the degree of acute anastomotic gastrointestinal anastomoses in the early postoperative period.

Rationally in the course of the study to carry out the recording procedures that will enable the subsequent detail and accurately carry out measurements and visual evaluation segment and gastroduodenostomy and will serve as a visual and documentary material of the diagnostic procedure.

The proposed method of determining the degree of acute anastomotic gastroduodenal anastomosis, consisting in a complex study gastroduodenostomy by the endoscopic method of examination and endoscopic ultrasonography, fairly objective and accurate, the n in the diagnostic results. Possible multiple dynamic procedure, which is quite important in assessing the degree of acute anastomotic and monitoring the effectiveness of the treatment. The method is simple, minimally invasive and rapid in execution, which is also important in patients in the early postoperative period.

The proposed method is informative, does not require the use of contrast agents available for use in the early postoperative period, is only allow to study in detail the layered structure of the wall in the area of the gastro-duodenal anastomosis. The method has a high accuracy and reliability when working with structures anastomosis and surrounding tissues.

The obtained evaluation criteria degree of anastomotic will allow time to diagnose the depth and severity of the inflammatory reaction in the area of the gastro-duodenalnogo transition and conduct adequate therapeutic measures. A necessary condition for quality treatment of patients operated with the formation of gastroduodenal anastomosis in the early postoperative period is an objective assessment of the severity and depth of the inflammatory reaction in the area of the anastomosis.

The results determine questions of tactics of conducting the patient, changes and additions of therapy, duration of discharge from institutional the Ara and the forecast for the remote period.

Figures

Figure 1. Endoscopic ultrasonogram structure gastroduodenostomy after resection of the stomach Billroth-I - catarrhal anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Inflammatory infiltration in the area of the anastomosis applies only to the mucous membrane. Is determined by the thickening of the mucosal layer with edema of the basal membrane in 2 times.

Figure 2. Endoscopic ultrasonogram structure gastroduodenostomy after resection of the stomach Billroth-I - erosive anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Inflammatory infiltration in the area of gastroduodenostomy apply to mucosal and submucosal layers with uniform thickening, the presence of surface defects mucosa (No. 1) is not deeper than the basal membrane of the mucosa and the presence of hyperechoic inclusions in the submucosal layer (No. 2).

Figure 3. Endoscopic ultrasonogram structure gastroduodenostomy after resection of the stomach Billroth-I infiltrative anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Inflammatory infiltration apply to mucosal, submucosal and muscle layers with violation of the architectonics of the muscle layer and the inability to determine gra the Itza between these layers.

Figure 4. Endoscopic ultrasonogram structure gastroduodenostomy after resection of the stomach Billroth-I - inflammatory-erosive anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Inflammatory infiltration in the area of gastroduodenostomy apply to mucosal, submucosal and muscle layers with uniform thickening, it is impossible to clearly define the boundaries between the layers. Broken architectonics muscle layer. In the mucosal and submucosal layer are determined by the surface defects in the form of a small point and linear hyperechoic inclusions is not deeper than the basal membrane of the mucosa.

Figure 5. Endoscopic ultrasonogram structure gastroduodenostomy after resection of the stomach Billroth-I - ulcerative anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Violated the integrity of the mucosal and submucosal layers involving muscle membrane in the form of hypoechoic area of destruction (No. 1), the bottom of which is defined hyperechoic necrotic mass, inflammatory infiltration apply to mucosal, submucosal, muscle layers violation of architectonics muscle layer and the boundaries between layers.

6. Endoscopic ultrasonogram structure gastroduodenostomy last the resection of stomach Billroth-I-ulcerative-perforated anastomosis. Transverse ultrasound slice relative to the axis of the gastro-intestinal tube. Violated the integrity of the mucosal, submucosal and muscle layers of the membrane in the form of hypoechoic plot destruction with hyperechoic necrotic masses (No. 1) and the spread of the inflammatory infiltration of all layers of the anastomosis with formation of infiltration anastomosis, preprocess as hypoechoic swelling of the structures on the outside wall of the stomach, abscess 25×15 mm in the form of a hydrophilic area of the spherical form with an irregular outer boundary associated with the line of suture anastomosis (No. 2).

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3. Zhizhin FS, Kapustin B.B. Clinical and endoscopic classification of acute anastomosis after resection of the stomach // journal of surgery. ICU. - 2002. - T. No. 6. 49 - 52. (prototype).

4. Burkov YEAR, "Endoscopic ultrasound in the diagnosis of diseases of the digestive system" in kN. Clinical guidelines for ultrasound diagnostics" vol Chapter No. 10. edited Mitkova CENTURIES, Medvedev M.V. PM: Vidar, 1997. P.279-294.

With the persons determining the degree of acute anastomotic gastroduodenal anastomosis, consisting in assessing the degree of inflammation gastroduodenostomy after endoscopic surgery for his research, including a visual assessment of the mucosal surface and soundness of welds in the area of anastomosis, characterized in that additionally provide endoscopic ultrasonography zone gastroduodenostomy with the criteria of the depth of the destruction of the wall of the anastomosis in layers and patterns identified modified area by successive examination of all layers of the wall of the stomach, the duodenum and the surrounding tissue at the anastomosis and if there is evidence of spread of the inflammatory infiltration only in the mucous membrane with the presence of thickening of the mucosal layer with edema of the basal membrane, depending on the severity of the edema is diagnosed with slightly pronounced edema ending epithelization the field of fistula, while the thickening of this layer of the mucosa due to the swelling in 2 times - catarrhal (surface) anastomosis, when determining the distribution of inflammatory infiltration at the mucosal and submucosal layers with the presence of surface defect is not deeper than the basal membrane of the mucosa, thickening of the mucosal and submucosal layers, the presence of small point or linear hyperechoic inclusions in the mucosal and submucosal layers on Instituut catarrhal-erosive anastomosis, the spread of the inflammatory infiltration at the mucosal, submucosal and muscular layers, the impossibility of a clear definition of the boundaries between these layers, the violation of architectonics muscle layer diagnosed infiltrative anastomosis, in addition to the above picture of the ultrasound signs of erosion in the form of a small dot or linear hyperechoic inclusions in the mucosal and submucosal layers, dilated blood vessels in the submucosal layer and fuzzy boundaries between these layers are diagnosed infiltrative erosive anastomosis, in violation of the integrity of the mucosal and submucosal layers involving muscle membrane in the form of hypoechoic area destruction, the bottom of which is defined hyperechoic necrotic mass, the distribution of inflammatory infiltration at the mucosal, submucosal muscle layers, with violation of the architectonics of the muscle layer and the absence of clear boundaries between the layers in the area of the defect is diagnosed destructive anastomosis, in violation of the integrity of the mucosal, submucosal and muscle layers in the form of a hypoechoic area of destruction with hyperechoic necrotic masses and the presence of a defect on the entire wall thickness in the area of gastroduodenostomy, the distribution of inflammatory infiltration of all layers of the anastomosis with formation of infiltration is anastomose, and preprocess, abscesses associated with the line of stitches anastomosis and the outer wall of gastroduodenostomy, diagnose destructive anastomotic complicated by the failure of the anastomosis.



 

Same patents:

FIELD: medicine, ophthalmology.

SUBSTANCE: one should carry out optic coherent retinal tomography before the onset of therapy and after it in 1 wk and in 1 mo. On a tomogram it is necessary to detect the availability of affected integrity in retinal layers and retinal thickness in the center and along the edge of fovea. In case, it is observed the escape of a defect and restoration of retinal layers and thickened retina in foveolar center up to 100 mcm and more and decreased retinal thickness along the edge of fovea up to 250 mcm and below therapy should be considered to be efficient and sufficient. If a tomogram illustrates decreased retinal defect in combination with decreased retinal thickness along the edge of fovea up to 250 mcm and less one should detect the flattening of the rupture. If a tomogram demonstrates broadened borders of macular rupture and increased retinal thickness along the edge of fovea one should consider the therapy conducted to be inefficient.

EFFECT: higher accuracy of evaluation.

5 dwg, 2 ex

FIELD: medicine, ophthalmology.

SUBSTANCE: one should carry out optic coherent retinal tomography before the onset of therapy and after it in 1 wk and in 1 mo. On a tomogram it is necessary to detect the availability of affected integrity in retinal layers and retinal thickness in the center and along the edge of fovea. In case, it is observed the escape of a defect and restoration of retinal layers and thickened retina in foveolar center up to 100 mcm and more and decreased retinal thickness along the edge of fovea up to 250 mcm and below therapy should be considered to be efficient and sufficient. If a tomogram illustrates decreased retinal defect in combination with decreased retinal thickness along the edge of fovea up to 250 mcm and less one should detect the flattening of the rupture. If a tomogram demonstrates broadened borders of macular rupture and increased retinal thickness along the edge of fovea one should consider the therapy conducted to be inefficient.

EFFECT: higher accuracy of evaluation.

5 dwg, 2 ex

FIELD: medicine, ophthalmology.

SUBSTANCE: one should analyze patient's genealogy, optic coherent tomography of ocular retina. According to tomogram one should evaluate the transparency of photoreceptors layer and its thickness, and, also, retinal thickness in the center. Under condition of autosomo-recessive type of inheritance and availability of retinal thickness in the center being 110±3.6 mcm and thickness of photoreceptors layer being 52.13±1.4 mcm it is possible to predict unfavourable disease flow. And under condition of autosomo-dominant type of inheritance and availability of retinal thickness in the center being 139±2.4 mcm, the thickness of photoreceptors layer being 73.43±2.6 mcm one should predict favorable disease flow. Moreover, in case of both flows of pigment retinitis the transparency of photoreceptors layer is shifted towards white color against standard chromatic scale of the device. The application of the present innovation enables to increase accuracy of detecting the above-mentioned disease in early juvenile age and provides the chance to evaluate its flow.

EFFECT: higher accuracy of prediction.

2 ex

FIELD: medicine, vascular surgery.

SUBSTANCE: one should measure the width of costoclavicular space due to ultrasound scanning at simultaneous visualization of patient's clavicle and the first rib due to detecting maximal distance between them. At distance being under 5 mm one should diagnose costoclavicular syndrome. The innovation enables to detect costoclavicular space due to US scanning at calculating average value of costoclavicular space being at norm.

EFFECT: higher efficiency of diagnostics.

1 dwg, 1 ex

FIELD: medicine.

SUBSTANCE: method involves carrying out sonographic examination for detecting inclusions available in cystic bile, evaluating contractile gallbladder function; biochemical study for determining bile lithogenicity properties and blood lipid composition; morphological study for examining mucous and submucous layer cells. When detecting hyperechogenic particles suspension, bile inhomogeneity, ointment-like bile, availability of internal granulated mucous membrane lining in the gallbladder, high echogenicity and gallbladder wall thickening by 1-2 mm, availability of non-movable parietal neoplasms of high echogenicity having granulated outline and structure, gallbladder bile release fraction being equal to or less than 36.6% and bile saturation with cholesterol index being equal to or greater than 1.02 and general blood cholesterol level being equal to or greater than 5.8 mmole/l, high density lipoproteins cholesterol equal to or less than 1.1 mmole/l, low density lipoproteins cholesterol equal to or greater than 3.8 mmole/l, triglycerides equal to or greater than 1.4 mmole/l as well as foam cells being found in the mucous membrane and submucous layer of the gallbladder and epithelium dystrophy being available and de-epithelialization sites on separate fibers being found, gallbladder cholesterosis is to be diagnosed.

EFFECT: high accuracy of diagnosis.

FIELD: medicine.

SUBSTANCE: method involves applying ultrasonic Doppler flowmetry techniques for determining blood circulation characteristics in orbital artery, central retinal artery and posterior short ciliary arteries. Their changes are recorded once. Injured eye is compared to intact eye or both injured eyes are compared to control group eyes. Changes in maximum systolic blood circulation flow rate Vs, minimum diastolic blood circulation flow rate Vd and peripheral resistance index Ri values are recorded. Vs threshold value dropping by 11%, Vd threshold value by 34.6%, Ri value growing by 11.8% in central retinal artery on the injured eye or on both eyes and Vs value dropping b y 25.4%, Vd by 42% and Ri value growing by 11% in the posterior short ciliary arteries being observed, chronic uveitis clinical course is diagnosed to be the case. Vs threshold value growing up by 11%, Vd threshold value by 12%, Ri value dropping by 9% in central retinal artery and Vs value growing by 25%, Vd by 29% and Ri value dropping by 10% in the posterior short ciliary arteries being observed, acute uveitis clinical course is to be diagnosed.

EFFECT: high accuracy of early stage diagnosis; accelerated treatment course.

FIELD: medical engineering.

SUBSTANCE: device has tube and metal ball. The ball is connected to the tube by means of thread. The ball is 1.5 cm far from the tube. The tube is manufactured from polyvinyl chloride. Its wall is 1 mm thick and 1500-1600 mm long. Two marks are available on the probe one showing distance to antral stomach section and distance to greater duodenal papilla.

EFFECT: accelerated examination method; controlled probe working end.

2 cl, 1 dwg, 1 tbl

FIELD: medicine, oncological urology.

SUBSTANCE: in pre-operational period one should detect patient's age, the availability of severe concomitant pulmonary pathology, clinical stage of tumor, intergrowth of prostatic capsule in case of finger-type rectal investigation, tumor localization in prostatic central area at ultrasound testing, intergrowth of prostatic capsule at ultrasound investigation, if a patient has got the closest relatives suffering with prostatic cancer or if a patient has got the closest relatives suffering with the cancer of another localization. It is necessary to calculate the value for the risk of local relapse by the following formula: R=-(0.046xAGE)+(1.01xCONCOMIT)+0.45x(CLIN T)+(1.78xPERRECT)+(0.65xTRUSI 1)+(0.74xTRUSI 2)+(0.87xRELATIV 1)+(0.05xRELATIV 2), where AGE - patient's age (yr); CONCOMIT - the availability of severe concomitant pulmonary pathology: 0 -yes, 1 - no; CLIN T - clinical stage of tumor: 1 -T1, 2 -T2, 3 - T3; PERRECT - intergrowth of prostatic capsule in case of finger-type rectal investigation: 0 - no, 1 - yes; TRUSI 1 - localization of prostatic tumor in prostatic central area in case of trans-rectal ultrasound investigation: 0 - no, 1 - yes; TRUSI 2 - intergrowth of prostatic capsule in case of trans-rectal investigation : 0 - no, 1 - yes; RELATIV 1 - if a patient has got the closest relatives suffering with prostatic cancer: 0 - no, 1 -yes; RELATIV 2 - if a patient has got the closest relatives suffering with cancer of another localization: 0 - no, 1 - yes. At values being R>0 one should predict the risk of local; relapse during 5 years. The innovation enables to carry out complex evaluation of the most informative risk factors of local relapse of prostatic tumor at pre-operational stage after radical prostatectomy in digital equivalent by taking into account individual clinical value of each risk factor.

EFFECT: higher efficiency and accuracy of prediction.

2 ex

FIELD: medicine.

SUBSTANCE: one should evaluate morphological signs of blood serum: the area of peripheral region, the number of fissures and crystallization region, and ultrasound features, as well: the structure of cholecyst's wall, choledochus' diameter, availability of free liquid in abdominal cavity and hemodynamics in cholecyst's wall in points according to certain criteria. According to the sum of points a patient should be referred to the group of low risk for the development of complications to carry out repeated investigation in 6-8 h, or to the group of moderate risk for the development of complications to carry out repeated investigation in 3 h, or to the group of high risk for the development of complications being an indication for conducting urgent operation. The innovation provides earlier detection of complicated flow of chronic calculosis cholecystitis and helps to carry out correction of curative algorithm in due time. It, also, improves results of therapy and shortens the terms of rehabilitation.

EFFECT: higher accuracy of diagnostics.

3 ex

FIELD: medicine.

SUBSTANCE: method involves carrying out ultrasonic examination of neck region. The ultrasonic examination is carried out by alternating scanning in frontal and frontolateral planes using superficial; transducers tuned at wavelengths of 5.0 MHz and 7.5 MHz in varying inclination angle from 45° to 135° from mental region downward along trachea to upper poles and thyroid gland isthmus level. Zones having echogenic parameters differing from those of normal tissues, tumor neoplasm availability is diagnosed.

EFFECT: high accuracy in visually determining laryngeal bulk neoplasms.

FIELD: medicine.

SUBSTANCE: method involves carrying out ultrasonic scanning examination of subclavian artery over its whole extent in physiological arm position with arterial blood pressure being measured in the middle one third of the arm. Next, when applying compression tests, blood circulation parameters variations are recorded in distal segment of the subclavian artery with arterial blood pressure being concurrently measured. Three degrees of superior thorax aperture syndrome severity are diagnosed depending on reduction of linear blood circulation velocity and arterial blood pressure compared to their initial values. Mild one takes place when linear blood circulation velocity reduction reaches 40% and arterial blood pressure 20% of initial level, moderate one when linear blood circulation velocity reduction reaches 70% and arterial blood pressure 50% and heavy one when linear blood circulation velocity reduction is greater than 70% of initial level and arterial blood pressure is greater than 50% to the extent of no blood circulation manifestation being observed in the subclavian artery.

EFFECT: high accuracy of diagnosis.

FIELD: medicine.

SUBSTANCE: method involves carrying out skeletotopic conjunction and organ element localization description relative to vertebra body. Neck organ picture is described in skeletotopic manner using anterior contour of cervical vertebra body and transverse processes in upper, median and inferior portion of cervical vertebra with the exception of the first and the second one.

EFFECT: high accuracy in diagnosing pathological processes in neck organs and creating computer models.

2 dwg

FIELD: medicine.

SUBSTANCE: method involves carrying out ultrasonic examination of aorta coarctation stenosis nature. Apex direction of angle formed with longitudinal axes of ascending and prestenotic aorta area is determined. Four aorta coarctation patterns are selected on measured values combination.

EFFECT: high objectiveness degree in determining aorta coarctation nature and selecting treatment mode.

4 dwg, 1 tbl

FIELD: medicine, urology.

SUBSTANCE: one should conduct subcutaneous prevocational tuberculin test and, additionally, both before the test and 48 h later it is necessary to perform the mapping of prostatic vessels and at decreased values of hemodynamics one should diagnose tuberculosis. The information obtained should be documented due to printing dopplerograms.

EFFECT: more reliable and objective information.

1 ex, 1 tbl

FIELD: medicine.

SUBSTANCE: method involves applying primary and repeated ultrasonic examination of abdominal cavity and evaluating symptoms. Patient drinks or receives as infusion more than 1 l of water or physiological salt solution cooled to 4-5° C in portions with 15 min long pauses during 30-60 min before carrying out repeated ultrasonic examination.

EFFECT: high reliability of early stage diagnosis.

FIELD: medicine.

SUBSTANCE: method involves introducing auto leucocytes marked with 99mTc-hexamethylenepropyleneaminooxime in intravenous bolus dose. Heart contour images are recorded first when the bolus passes through heart cavities, pulmonary artery and ascendant aorta arc. Single-photon emission computer tomography of chest is carried out 3.50.5 h for discovering inflammation foci with exact correspondence of patient body to initial one. Tomographic slices are superimposed over heart contours to localize the inflammation foci.

EFFECT: high accuracy of measurements; reduced radiation loading; accelerated examination process.

7 dwg

FIELD: medicine.

SUBSTANCE: method involves recording choledochus diameter changes in carrying out Oddi sphincter relaxation with isosorbide dinitrate in combination with nutrient loading by means of ultrasonography. Diagnosis is carried out in two stages. Maximum choledochus diameter is determined in the morning with empty stomach at the first day at the beginning of the study. The value is taken as the initial value (Din). Then, standard breakfast is given to the patient like 200 ml creamy yogurt containing 10% fat and choledochus diameter (dxi,j) is measured twice with 40 min long pause. Diameter variation (δDij) is measured at 40 and 80 min relative to initial value using formula δDij = (Din - dxi,j)/Din*100%, where i is the parameter values at 40 min of study; j the parameter values at 80 min of the study. At least one δDij value becoming greater than 25%, the second study stage is carried out the next day. 10 mg of isosorbide dinitrate is given to the patient with empty stomach in the morning. 40 min later, the first choledochus diameter D1 value is measured and standard breakfast is given to the patient like at the first day study. Maximum choledochus diameter (dxi,j) is once more measured twice with 40 min long pause at 40 and 80 min, respectively. Diameter variation (δDij) is measured relative to the first measurement using formula δDij = (D1 - dxi,j)/D1*100%, where i is the parameter values at 40 min of study; j the parameter values at 80 min of the study. At least one δDij value becoming greater than 25%, organic change of Oddi sphincter is to be diagnosed. At least one δDij value becoming equal to or less than 25%, functional disorder is diagnosed.

EFFECT: high reliability of diagnosis.

2 dwg

FIELD: medicine.

SUBSTANCE: method involves carrying out multi-positional ultrasonic scanning in real-time mode applied to anterior tibia tuberosity surface. 2 mm to 2 cm large hyperechogenic fragment(s) with acoustic shadow remaining at the same place when bending knee joint is/are found.

EFFECT: high accuracy of diagnosis.

1 dwg

FIELD: medicine.

SUBSTANCE: method involves determining liquid content volume in stomach cavity in 60 min after taking 150 ml of boiled water in performing ultrasonic examination through frontal abdominal cavity wall. Repeated examinations are done every 5 min later on. Liquid being observed in the stomach for the second time or many times in the amount of 10% of total volume or more, duodenogastric reflux is considered to be the case.

EFFECT: high objectivity of diagnosis; reduced risk of traumatic complications; low costs.

FIELD: medicine.

SUBSTANCE: method involves carrying out Doppler tissular echocardiography examination. Left ventricle myocardium segments movement characteristics are measured in time in each j-th segment. Regional myocardium productivity index Ij of the left ventricle is measured with formula containing isovolumic contraction time, isovolumic relaxation time and withdraw period duration being used. Ij values estimation is carried out in segments fed by single coronary artery branch with blood. Left ventricle regional myocardium productivity index value being not less than in two segments fed by single coronary artery branch with blood and equal to or greater than 0.8, cardiac ischemia disease is to be diagnosed.

EFFECT: simplified diagnosis method.

2 tbl

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