RU2581709C2 - Method for prevention of postoperative complications when closing perorated ulcer of duodenal cap - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and surgery. When closing perorated duodenal ulcer, Tachocomb Plates are applied. Nasointestinal probe with duodenal balloon is inserted into small intestine. On front surface of balloon Tachocomb Plate is installed. Ballon is inflated and plate is compressed to area of suture line. Stomach is decompressed and drained through 3 or 4 side holes proximally to duodenal balloon in gastric part of probe. Decompression and drainage of small intestine is performed through multiple side holes distally to duodenal balloon along 60 cm. If there is "mirror" ulcer of duodenum rear wall, its surface is covered with Tachokomb Plate. Duodenal balloon provides compression of both plates.

EFFECT: method provides prevention of postoperative complications due to reliable haemostasis, effective drainage, and decompression around defect zone of initial duodenum.

2 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to abdominal surgery.

In duodenal surgery, the most dangerous and leading complications in operations for perforated ulcers are: inconsistency of sutures, bleeding from the suture line or from a “mirror” ulcer of the posterior wall, stricture of the lumen and paralytic intestinal obstruction. Especially with a high frequency these complications accompany interventions in elderly and elderly patients, with metabolic disorders, immunodeficiency, anemia, tumors, as well as with peritonitis and the presence of inflammatory changes in the duodenal wall, as well as with technical defects of the operation.

Analogs

A.V. Schott and A.A. Zaporozhets (1990), in order to prevent infection of the abdominal cavity through the intestinal suture, they suggested intraoperatively introducing an antibacterial suppository containing furatsilin and kanamycin into the lumen of the anastomosis.

A.A. Umarov et al. (1977) for the prevention of suture insolvency, it was recommended to cover the seam line with a plastic film, hemming it from the mucous membrane.

F.G. Kulachek (1986), to protect the intestinal suture in conditions of peritonitis, proposed the use of intraluminal endoprostheses consisting of gelatin, collagen and a broad-spectrum antibiotic, which were introduced into the lumen of the small intestine anastomosis.

B.F. Kasatkin et al. (1999) developed a method of continuous irrigation and sealing of the suture line of the esophageal anastomosis from the contents of anastomosed organs with a suture line.

E.S. Bocharnikov et al. (1999) to prevent esophageal suture insolvency, a probe was proposed with a plugged end and a cuff at the end, the flushing channel of which is located above the inflatable cuff.

B.Z. Totikov et al. (2001) when forming a compression colonic anastomosis, they propose to put on a plastic “sleeve” on the AKA-2 apparatus, which during anastomosis protects the anastomosis from the effects of the contents, which provides a significant improvement and acceleration of reparative processes.

The disadvantages of the above methods of preventing postoperative complications from the intestinal suture are: 1. The inability to effectively use them in the initial part of the duodenum. 2. Uncontrollability. 3. The lack of opportunities for compression hemostasis, separate decompression and drainage of the stomach and small intestine, as well as for the prevention of stenosis of the lumen of the duodenum.

Prototype

As a prototype, we took the method developed by Gorsky V.A. Technical aspects of the application of the Tachocomb biopolymer during operations on the abdominal organs. (Surgery (5) 2001, p. 43-46).

The purpose of the invention

The aim of the invention in terms of the method is the prevention of postoperative complications (inconsistency of sutures, bleeding, stenosis in the suture line, paralytic intestinal obstruction) during operations for perforated ulcers of the anterior wall of the initial part of the duodenum in the presence of peritonitis and "mirror" ulcer of the posterior wall.

The aim of the invention in terms of the device is to provide compression hemostasis and decompression and drainage of the small intestine in patients with peritonitis in the early postoperative period.

The invention in terms of method

The essence of the proposed method consists in intraluminal dosed controlled compression of the anterior wall of the duodenal bulb in the region of the suture line and the posterior wall in the area of the "specular" ulcer using an inflatable duodenal balloon of the nasointestinal probe of the proposed design.

The proposed method is illustrated in FIG. 1, where 1 is the esophagus, 2 is the stomach, 3 is the gastric part of the nasointestinal probe, 4 is the pyloric sphincter, 5 is the anterior wall of the duodenum, 6 is the posterior wall of the duodenum, 7 is the duodenal balloon of the nasointestinal probe, 8 is the intestinal part of the naso-intestinal probe , 9 - lateral openings of the nasointestinal probe. FIG. 2 is a schematic illustration of a probe of the proposed design.

After laparotomy, the peritoneal exudate is evacuated, primary lavage of the abdominal cavity is performed with an antiseptic solution, then the duodenum is revised, and the perforated ulcer is excised or sutured. A visual examination of the posterior wall of the duodenum is carried out for the presence of an ulcer, or examination by intraoperative duodenoscopy. Through the nasal passage, esophagus and stomach, the nasointestinal probe of the proposed design is carried out into the initial part of the duodenum to visualize the duodenal balloon in the wound of the anterior wall of the initial part of the duodenum. When diagnosing a “mirror” ulcer of the posterior wall of the duodenal bulb, its surface is covered with a Tachocomb plate with dimensions exceeding the area of the ulcer itself. On the front surface of the duodenal balloon of the nasointestinal probe, a second Tachocomb plate is installed for compression on the suture line. Then, the anterior wall of the duodenum is sutured with one- or two-row sutures with atraumatic suture material. Further duodenal balloon is inflated to a minimal tensile wall of the duodenal bulb, but not more than _^1/4 of its original diameter, which does not lead to disruption of blood flow to the gut wall.

An example of a specific implementation of the method

08/13/2013 at 13.20 a.m., patient MI, 18 years old, with complaints of severe abdominal pain that arose suddenly during physical activity 40-50 minutes before, was delivered to the Republic of Belarus No. 2-TsSEMP ambulance team. Arrival at the hospital. A history of duodenal ulcer. On "D" the account is not composed, anti-ulcer therapy did not receive. Objectively: the abdomen did not participate in the act of breathing; during palpation it is “board-like” tense. With percussion of the abdomen, hepatic dullness was absent. Pulse 72 beats. in minutes A / D - 120/80 mm Hg On the survey roentgenogram of the abdominal cavity organs, “free gas” was determined under the right dome of the diaphragm. Auscultatory peristaltic noises were not heard. An upper mid laparotomy was performed under ETN. In the abdominal cavity, up to 300-400 ml of turbid effusion with fibrin, which was evacuated with an electric suction pump. During the audit, a perforated ulcer of the anterior wall of the initial part of the duodenum with perifocal inflammatory infiltrate d = 5-7 mm was diagnosed. Performed an operation - excision of perforated ulcers within healthy tissues. Hemostasis. When examining the posterior wall, a “speculum ulcer” d = 4-5 mm was diagnosed. On the surface of the ulcer of the posterior wall, a Tachocomb plate is placed, the area of which is larger than the area of the ulcer. Through the nasal passage, esophagus and stomach, a nasointestinal probe of the proposed design was carried out in the initial section of the duodenum. A second Tachocomb plate was placed on the front visible surface of the duodenal balloon of the nasointestinal probe, exceeding the length and width of the suture line. The front wall of the duodenum was sutured with single or double row sutures. Then the duodenal balloon was inflated to the level of light compression. The outer end of the probe was fixed to the nasal passage. In this case, the distal end of the probe was at a depth of 60 cm from the pyloric pulp and allowed the contents of the small intestine to be evacuated. The postoperative period was uneventful. Paresis resolved for 2-3 days. The wound healed by primary intention. The nasointestinal probe was removed on day 6. During the control FGDS it was established that there are no ulcers, the suture line is flat, the lumen in the suture area is not narrowed. The ulcer healed without any signs. Discharged on the 10th day. Antiulcer therapy recommended.

Similar operations were performed in 5 patients with a good clinical effect and without any complications. One of them with laparoscopic suturing perforated ulcers.

Features of the method, distinctive from the prototype

According to the prototype method, the seam line is covered with a plastic film, hemming it from the mucous membrane. According to the proposed method, an intraluminal dosed controlled compression of the anterior wall of the duodenal bulb in the suture line and the posterior wall in the area of the "specular" ulcer is carried out using an inflatable duodenal balloon of the nasointestinal probe of the proposed design. On the mucous membrane in the area of the suture line and on the surface of the “specular” ulcer, plates from the Tachocomb are applied.

The positive effect of the application of the proposed method

The method provides prevention of postoperative complications (inconsistency of sutures, bleeding, stenosis in the suture line, paralytic intestinal obstruction) during operations for perforated ulcers of the anterior wall of the initial part of the duodenum in the presence of peritonitis and "mirror" ulcer of the posterior wall. In addition, compression hemostasis is provided, decompression and drainage of the small intestine in patients with peritonitis in the early postoperative period is carried out.

Information sources

1. Gorsky V.A. Technical aspects of the application of the Tachocomb biopolymer during operations on the abdominal organs. Surgery (5), 2001, p. 43-46.

Claims (2)

1. A method for the prevention of postoperative complications when suturing a perforated duodenal ulcer, including providing hemostasis and tightness of the suture line by applying a plate from the Tachocomb, characterized in that a nasointestinal probe with a duodenal balloon is infused into the small intestine through the nasal passages, esophagus, and stomach carried out through a tube, the proximal end of which ends with a valve, and the distal - opens in the lumen of the balloon, while on the front surface of the balloon set a plate from Tahokomb and a cylinder provides compression in the area of the seam line; provide decompression and drainage of the stomach through 3-4 lateral openings proximal to the duodenal balloon in the gastric part of the probe; provide decompression and drainage of the small intestine through multiple lateral openings distal to the duodenal balloon for 60 cm. 2. The method according to p. 1, characterized in that in the presence of a "mirror" ulcer of the posterior wall of the duodenum, its surface is covered with a plate of Tachocomb, and its duodenal balloon provides compression.

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