Pyloroplasty according to Heineke - Mikulich Radetsky with suturing of a bleeding vessel in an ulcer. Pyloroplasty according to Finney: purpose, preparation for surgery, performance, methods, technique, stages, recovery period and rehabilitation Truncal vagotomy with pyloroplasty

The term “pyloroplasty” refers to a type of surgical intervention, during which the opening located between the stomach and duodenum is widened. This is necessary in order to ensure the normal passage of processed food into the small intestine. Currently, there are several techniques for performing the operation. The optimal method is Finney's pyloroplasty.

Indications

During the surgical procedure, the integrity of the digestive tract is not compromised. The task of doctors is only to expand the pathologically narrowed area, which occurs due to the influence of various kinds of provoking factors. Phyloroplasty according to Finney is not difficult. In addition, the risk of developing negative consequences is minimal. Because of this, doctors may include surgery in the treatment regimen for a large number of patients.

The main indications for Finney pyloroplasty are:

in particular, the pyloric region. As a rule, this pathology occurs in elderly patients.
Scar-ulcerative stenosis in young children.
Ulcer. Finney pyloroplasty is performed even in the presence of complications such as profuse bleeding and perforations.
Congenital pyloric stenosis in infants.

In addition, the operation is indicated for people who suffer from concomitant diseases that require vagotomy. This term refers to surgical dissection of the branches of the vagus nerve or its entire trunk, after which the secretion of hydrochloric acid decreases.

Preparation

Finney's pyloroplasty is an operation that requires preliminary preparation. First of all, the patient must submit blood and urine tests, as well as undergo an X-ray examination. Based on the diagnostic results, the doctor makes a decision regarding the advisability of surgical intervention.

Immediately before the operation, the patient is strictly forbidden to eat or drink water. The duration of the fasting period should be at least 10 hours. An obligatory stage in preparation is administering a cleansing enema. If the patient suffers from nausea and/or vomiting, the stomach is emptied using a special tube.

Technique

The operation is performed exclusively under general anesthesia. The patient is put into a sleep state in which painful sensations are completely blocked. After this, the operation begins. The Finney pyloroplasty technique is not particularly difficult for surgeons.

The operation is carried out according to the following algorithm:

To provide access to the pylorus, the doctor makes an incision in the upper abdomen. In recent years, the operation has increasingly been performed using laparoscopic instruments, which eliminates the need to cut the anterior wall of the peritoneum.
The doctor places sutures 4-6 cm long, which connect the stomach and duodenum along the greater curvature. In this case, the gatekeeper should be at the top.
The surgeon opens the lumen of the duodenum and stomach. The incision should be arched.
In order to stitch the walls of the anastomosis, the doctor applies a continuous suture. It covers all layers of the stomach and duodenum.
The next task of the surgeon is to prevent tension on the sutures. To do this, he mobilizes the duodenum using the Kocher technique. The essence of the method is to release the descending part of the organ and then suturing its inner edge with the greater curvature of the pyloric part of the stomach.
The surgeon forms the anastomosis. In other words, it is a connection of tissues.
After Finney pyloroplasty, the doctor restores the integrity of the muscle tissue. Staples or sutures are placed on the skin at the incision site.

The duration of the operation is on average 1-2 hours.

Recovery period

The patient is constantly monitored for the first few hours after surgery. Nurses regularly monitor blood pressure, body temperature, respiratory rate and heart rate.

In the first 1-2 days, nutrient solutions are injected intravenously into the patient’s body. After the operation, you are allowed to drink only a little water (up to 0.5 l). From the second day this restriction is lifted. The patient is transferred to therapeutic nutrition. The diet involves frequent meals, but the portions should be very small. The expansion of the diet occurs gradually.

From the second day, it is also allowed to take short walks and do breathing exercises. Each time the intensity of physical activity should become greater. The exception is situations in which the patient does not feel well or experiences severe pain.

The sutures are removed 8-10 days after Finney gastric pyloroplasty. The patient is discharged if his condition is assessed as satisfactory and the results of laboratory tests do not cause concern.

Possible complications

The possibility of undesirable consequences cannot be excluded. But it is important to know that they appear only in isolated cases. Among the complications:

peritonitis;
pancreatitis;
internal bleeding;
disruption of the process of evacuation of partially digested food from the stomach;
chronic diarrhea;
violation of intestinal integrity;
formation of a hernia in the incision area.

The risk of complications increases with dehydration, smoking, unbalanced diet, and obesity. Provoking factors also include respiratory diseases, old age, bleeding disorders and heart pathologies.

Finally

During Finney pyloroplasty, the surgeon expands the pathologically narrowed area located between the stomach and duodenum. Currently, this method is considered optimal for solving this problem. In addition, it is not associated with a high risk of postoperative complications. The criteria for a successful intervention are the patient’s satisfactory condition, good test results, and restoration of normal evacuation of partially digested food.

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Technical features of surgical interventions

Patient position on the operating table when performing laparotomy should create optimal conditions for visualization and manipulation of the organs of the upper abdominal cavity, including the esophagogastric junction. For this, the patient is placed on a cushion 10-15 cm high, the lower edge of which is at the level of the xiphoid process of the sternum, which allows for freer manipulation in the area of the esophageal opening of the diaphragm.

The position of the patient on the table when performing minimally invasive interventions is usually traditional, but it is more convenient to operate if the patient is placed with his legs apart. In the first case, the surgeon stands to the left of the patient, the assistants to the right; in the second, the surgeon is between the patient’s legs, the assistants are on both sides of him. The surgical field is processed and delimited in such a way that, if necessary, it is possible to quickly and conveniently switch to laparotomy.

Access. To perform surgical interventions for complicated ulcers, a midline incision is common, which gives a good exposure of all parts of the stomach, is characterized by low trauma and speed of execution, which is important for emergency surgery. This access also provides the most favorable conditions when performing vagotomy. For a midline incision, the entire distance from the xiphoid process to the umbilicus is used. It is often advisable to extend the incision upward to the base of the xiphoid process and downward, bypassing the umbilicus on the left.

Access for laparoscopic bilateral subdiaphragmatic vagotomy the following. After applying carbodioxyperitoneum using a Veress needle and diagnostic laparoscopy (the laparoscope is inserted paraumbilically), trocars are installed in the right and left mesogastric areas and the right and left hypochondrium.

For pyloroplasty from mini-laparotomy use right-sided para rectal access 5-7 cm long in the projection of the gastroduodenal junction.

Revision of the abdominal cavity. Gastroduodenal ulcers of significant size are easily detected by the characteristic signs of the inflammatory process, as well as by palpation through the wall of the organ, especially when bimanual after dissection of the gastrocolic ligament. It should be remembered that the compacted head of the pancreas or retrogastric lymph nodes can be mistaken for an ulcerative crater.

A low postbulbar ulcer or diverticulum of the descending and lower horizontal part of the duodenum is easier to detect after mobilizing it according to Kocher. It must be remembered that sometimes a pyloric sphincter can be mistaken for an ulcerative infiltrate, the localization of which can be easily determined visually by the pyloric vein running across the pylorus ( v.pylorica).

When lowering the stomach, it is possible to examine the lesser and greater curvature, the area of the fundus of the stomach. After weakening the traction on the stomach, the abdominal esophagus and the entire anterior wall of the stomach are examined by palpation. A detailed revision of the posterior wall of the stomach is possible after dissection of the gastrocolic ligament (penetration of the ulcer into the pancreas). Necessary elements of an audit of the abdominal organs are examination of the liver (signs of cirrhosis), spleen (increase in size), vessels of the portal system, small intestine (bleeding tumors), pancreas (signs of chronic pancreatitis, adenomas in Zollinger-Ellison syndrome).

For diagnostic purposes it can be performed gastrotomy(in some cases this is necessary, despite the high information content of endoscopy), when, as a result of gastric inspection, the preoperative diagnosis of an ulcer is not confirmed or is doubtful. The most justified are a longitudinal incision through the pylorus or a transverse incision in the upper part of the stomach. Inspection of the stomach from the inside (if there are no specific instructions during palpation) is recommended to begin through the first incision. Its length is about 6 cm, which allows you to examine the antrum of the stomach and the initial part of the duodenum. After emptying the stomach of its contents, the edges of the gastric wound are widened with narrow hooks and the mucous membrane is carefully examined. Using a finger inserted into the gastrotomy opening, the descending part of the duodenum is examined.

If the source of bleeding is not found, and fresh blood comes from the upper parts of the stomach, clamps are applied to the wound in the pyloric area and a gastrotomy is performed in the upper part of the stomach. A wide cross-section and the use of retractors allow a thorough examination of the mucous membrane of the body of the stomach, the cardia area, and the esophageal opening.

The incisions in the stomach wall are closed with 2 rows of sutures. The pyloroduodenal incision is sutured in the transverse direction, which is essentially a stage of the Heineke-Mikulich pyloroplasty operation. A thorough examination of the stomach, duodenum and adjacent organs is an important stage of the operation, which has not only diagnostic but also tactical significance, as it allows one to make a final decision on the nature of the intervention (for example, refusing gastrectomy in favor of a technically simpler operation).

In cases where a well-planned inspection does not reveal the source of bleeding, one should think about rare causes of bleeding (hemobilia, pancreaticointestinal fistula, etc.) or the possibility of systemic diseases. Performing a “blind” gastrectomy or vagotomy with pyloroplasty when the source of bleeding is undetected is considered unacceptable.

Operations on the stomach and duodenum. Surgical intervention for a bleeding ulcer includes 2 stages: first- direct surgical hemostasis for a bleeding ulcer (suturing the ulcer with vessels, excision or extraduodenization of the ulcer followed by pyloroplasty) and second, aimed at reducing the acid-peptic factor. Vagotomy serves as the first stage of surgical intervention, performed urgently when the bleeding has stopped. In an emergency situation, with ongoing bleeding, it is preceded by gastric surgery to quickly stop profuse bleeding.

Some surgeons prefer to perform vagotomy blindly, by touch, isolating and crossing the nerve trunks deep in the wound. Meanwhile, the final therapeutic effect of surgery depends to a large extent on the completeness of the intersection of nerves, which can run through several trunks. Esophageal opening ( hiatus oesophageus) is opened for viewing after retraction of the left lobe of the liver with a long retractor. Detect by palpation hiatus, which is facilitated by a thick gastric tube inserted into the esophagus. A transverse incision of the thin layer of peritoneum covering the diaphragm is made slightly above the esophageal opening, closer to the phrenic vein. The length of the incision is about 4 cm. Bleeding here is usually minimal. Using a finger, use a careful peeling motion to examine the distal 3-5 cm of the esophagus along its entire circumference. The surgeon tries to determine the location and number of branches of the anterior (left) and posterior (right) vagus nerves.

By pulling the stomach down, the esophagus is slightly lowered from the mediastinum, while the anterior vagus nerve is clearly palpable in the form of a stretched string. It usually runs along one trunk, located along the anterior surface of the esophagus or slightly to the right. The nerve is taken with a special clamp and carefully isolated from the connective tissue sheath. Clamps are applied to the selected area from above and below. A section of the nerve 2.5-3.5 cm long is excised and sent for histological examination. Both ends of the vagus nerve are tied with nylon ligatures. The right or posterior nerve is easier to detect by pulling the stomach to the left and down.

It should be remembered that the posterior vagus nerve at this level extends 1 cm or more from the esophagus, located at the right phrenic crus. It is taken with a clamp, and the area is also excised in compliance with the details described above.

At the final stage, the surgeon carefully palpates the entire circumference of the esophagus in search of additional branches of the nerve that must be isolated and dissected. After careful hemostasis, the incision of the diaphragmatic peritoneum is sutured with several interrupted sutures.

Laparoscopic truncal vagotomy. The assistant moves the left lobe of the liver upward using a retractor inserted through a trocar in the right hypochondrium. For ease of manipulation, the stomach is grasped in the avascular zone along the greater curvature with a Babcock endoclamp inserted through a trocar in the left mesogastric region, and pulled down and to the left. The lesser omentum is opened in the immediate vicinity of the esophagogastric junction, forming a window in the avascular area. After this, through the cavity of the lesser omentum, the peritoneum covering the right leg of the diaphragm and the abdominal part of the esophagus is dissected longitudinally for 3-4 cm. The right leg of the diaphragm is retracted from the esophagus. A thick gastric tube allows better identification of the esophagus. The diaphragmatic-esophageal ligament is crossed, the tissues are pushed apart bluntly. Deep in the wound, the trunk of the posterior vagus nerve is exposed in the fatty tissue in the form of a white thread. It is lifted upward with a hook and freed from the small vessels accompanying it. After this, the vagus nerve is divided between 2 pre-applied clips. Another method of intersection is also used: the nerve trunk is coagulated for 2-3 cm and then transected. After dissecting the peritoneum over the anterior surface of the abdominal esophagus, using traction on the stomach and rotation of the esophagus with instruments, the anterior and left surfaces of the esophagus are isolated and the anterior vagus nerve is transected. The abdominal cavity is drained if necessary, and the trocars are removed.

Pyloroplasty according to Finney with suturing of a bleeding vessel in an ulcer. This type of pyloroplasty is more justified in case of combined complications of duodenal ulcer (combination of bleeding with cicatricial ulcerative stenosis), when pyloroplasty according to Heineke-Mikulich and Judd often does not provide adequate drainage of the stomach. The final result of organ-preserving surgery with vagotomy largely depends on this.

Finney's pyloroplasty differs from other methods of pyloroplasty in that it creates a wider outlet from the stomach. At the same time, it is technically feasible provided that there are no obstacles to the free mobilization of the descending part of the duodenum and its comparison with the pyloric part of the stomach. During pyloroplasty according to Finney, the descending part of the duodenum is mobilized according to Kocher: the peritoneum is dissected in an avascular area along the lateral edge of the intestine. Seromuscular sutures connect the greater curvature of the pyloric stomach with the inner edge of the duodenum (Fig. 52-1).

Rice. 52-1. Pyloroplasty according to Finney: a - placing an internal (posterior) suture between the medial wall of the duodenum and the outlet of the stomach; b - dissection of the anterior wall of the stomach and duodenum; c - application of an external (front) continuous suture; d - anterior outer row of serous-muscular sutures, completing the formation of the anastomosis.

The upper seam is located immediately at the pylorus, the lower one - at a distance of 7-8 cm from it. The anterior wall of the stomach and duodenum is dissected with a continuous arcuate incision. Using suction, the contents of the stomach and duodenum are removed, which makes it possible to examine the source of bleeding. After this, the arrosion vessel is stitched at the bottom of the ulcer in 2 places (above and below the arrosion) along with the tissues. To avoid cutting through the callous edges of the ulcer, the ligature should capture a healthy 0.5-1 cm from the ulcerative defect and pass under the bottom of the ulcer (Fig. 52-2).

Rice. 52-2. Stopping bleeding: a - suturing the arrozed gastroduodenal artery at the bottom of the ulcer; b - blood supply to this area (diagram).

The second version of the hemostasis technique for bleeding from an ulcer of the posterior wall of the duodenum is used in cases where it is not possible to accurately determine the localization of the arrozen vessel in the bottom of the ulcer, and the nature and intensity of hemorrhage makes one think about damage to the small branches of the gastroduodenal artery ( a. gastroduodenalis). In this case, 2 figure-of-eight sutures are applied through the ulcerative crater; the needle is injected, retreating 0.5-1 cm from the callous edges, and advanced further under the bottom of the ulcer (Fig. 52-3). When tying sutures, the bleeding vessels are compressed by tissue, and the bottom of the ulcer is, as it were, tamponed with the mucous membrane.

Rice. 52-3. Variant of hemostasis technique for bleeding from an ulcer of the posterior wall of the duodenum.

The gastroduodenotomy wound is closed as follows. A posterior internal suture is placed with a continuous, overlapping absorbable suture to ensure reliable hemostasis (see Fig. 52-1c). Then the anterior inner row is performed using a Schmiden-type screw-in suture from the lower corner of the incision upward towards the pylorus. The anterior outer row of interrupted seromuscular sutures completes the formation of the anastomosis (see Fig. 52-1d).

Extraduodenization of a bleeding ulcer with Finney pyloroplasty. The need for a similar method of operation for a bleeding duodenal ulcer arises in the case of its large size, localization on the posterolateral wall of the bulb and, as a rule, with penetration into the head of the pancreas and the hepatoduodenal ligament. After mobilization of the duodenum according to Kocher, the posterior wall of the pyloroplasty is formed and a horseshoe-shaped gastroduodenotomy is performed. The edges of the ulcer are excised along the lateral edge of the duodenal bulb. The remaining bottom of the ulcer on the tissues of the hepatoduodenal ligament and the head of the pancreas is removed (forced) beyond the lumen of the duodenum, while the posterior and lateral walls are partially formed with separate screw-in sutures on an atraumatic needle. Two rows of sutures close the anterior wall of the pyloroplasty (Fig. 52-4).

Rice. 52-4. Stages of extraduodenization of a duodenal ulcer penetrating into the hepatoduodenal ligament when performing pyloroplasty according to Finney: a - the penetrating ulcer is excised during the formation of pyloroplasty; b - pyloroplasty according to Finney, the bottom of the ulcer remains on the hepatoduodenal ligament.

Pyloroplasty according to Heineke-Mikulicz. Sutures are placed on the duodenum along the edges of the anterior semicircle of the pylorus. A wide pyloroduodenotomy is performed with a longitudinal incision. Once a bleeding ulcer is detected, it is treated using the methods described above. The pylorotomy incision is closed according to the following scheme. The stay sutures are pulled, transforming the longitudinal incision of the stomach and duodenum into a transverse one. A continuous wrapping suture is applied with an absorbable thread, covering the entire thickness of the mucous membrane, which ensures good adaptation of the stitched wound edges. The second row of seromuscular sutures is formed without rough tissue screwing.

Pyloroplasty according to Judd performed when a bleeding ulcer is localized on the anterior wall of the duodenum. After diamond-shaped excision of the ulcer, the resulting pyloroduodenotomy wound is closed in the transverse direction, as with pyloroplasty according to Heineke-Mikulich (see Fig. 51-7).

Rice. 51-7. Pyloroplasty according to Heineke-Mikulich: a - excision of a perforated ulcer with an electric knife; b - suturing the defect in the organ wall with separate sutures in the transverse direction.

Pyloroplasty from minilaparotomy access. The technical execution of pyloroplasty according to Finney, Heineke-Mikulich or Judd is fully consistent with the schemes for these operations outlined above. However, it should be noted that the technical features of performing pyloroplasty according to Finney require mobilization of the duodenum according to Kocher. If it is possible to perform the laparoscopic stage of the operation first, then it is preferable to mobilize the duodenum laparoscopically and then proceed to a mini-laparotomy.

Gastric resection (antrumectomy with vagotomy). For duodenal ulcers in patients with high secretion of hydrochloric acid, resection of 2/3-3/4 of the stomach can be reliable in terms of preventing recurrence of the ulcer. Nevertheless, preference should be given to resection of 1/2 of the stomach (hemigastrectomy) or even anthrumectomy in combination with vagotomy (the truncal vagotomy technique is described above) as a functionally more advantageous operation.

At bleeding stomach ulcers resection is indicated. Different levels of localization of gastric ulcers necessitate the removal of sections of the lesser curvature and body of the stomach of different lengths. However, even in cases of highly localized ulcers, dissection of the gastric wall along a broken line (“staircase” resection) allows for a relatively economical resection.

Considering that many monographs describe in detail the stages and technique of performing gastric resection, we allow ourselves to dwell only on the features of this type of intervention for a bleeding ulcer.

Closure of a difficult duodenal stump. It is these difficulties that arise with large bleeding ulcers that penetrate into the head of the pancreas. The most rational technique in such cases is mobilization of the duodenum while leaving the base of the ulcer in place. Reliable suturing of the duodenal stump can most easily be achieved using a technique (Fig. 52-5), described in the literature as the Graham method (Graham R.R. 1933).

Rice. 52-5. Closure of the duodenal stump using the Graham method: a - the anterior wall of the duodenum is dissected, a callous ulcer is visible on the posterior wall; b - gastrectomy was performed, the bottom of the ulcer remained on the head of the pancreas; c - the anterior and posterior walls of the duodenum are sewn together, the stump of the duodenum is sutured to the pancreatic capsule with separate sutures; d - final view of the covered duodenal stump.

In some cases, when large vessels are involved in the ulcerative process, in addition to mobilization and atypical closure of the duodenal stump, there is a need to ligate the proximal and distal ends of the gastroduodenal artery in order to stop ongoing bleeding.

Typical intraoperative complications

Among the errors and dangers that accompany truncal vagotomy, the following should be mentioned.

Damage to the esophageal mucosa, which, if unnoticed, will lead to severe mediastinitis.
Damage to the pleura during manipulations in the mediastinum at the time of mobilization of the esophagus or isolation of the posterior trunk of the vagus nerve.
Tear of the diaphragmatic crura during rough manipulations, which can lead to the formation of a hiatal hernia if the previous anatomical relationships are not restored.

When performing laparoscopic truncal vagotomy, one should remember the possibility of developing coagulative necrosis of the esophageal wall.

Management of the patient after surgery

Features of the management of the immediate postoperative period depend on the severity of the patient’s condition (degree of blood loss, advanced age and concomitant diseases), as well as on the nature of the surgical intervention performed: gastric resection with restoration of the continuity of the digestive tract by one of the types of gastrointestinal anastomosis or organ-preserving operations(stopping bleeding with vagotomy and drainage of the stomach).

Immediately after organ-sparing operations with vagotomy, a course of antiulcer treatment is prescribed, including proton pump inhibitors or the latest generation of H2 receptor blockers, as well as a complex of anti-Helicobacter therapy. In addition, after such operations, it is necessary to prevent motor-evacuation disorders of the operated stomach (prokinetics, physiotherapy, timely tube decompression of the stomach). In a number of patients with a high probability of developing postoperative motor disorders (a combination of bleeding with stenosis, profound anemia and hypoproteinemia), in order to prevent them, it is advisable to insert a nasojejunal tube intraoperatively, planning nutrition through it in the early postoperative period.

Basic principles of postoperative management

Eating by mouth. Liquid intake in limited quantities (up to 500 ml) is allowed, as a rule, already on the first day of the postoperative period (not counting the day of surgery). From the 2-3rd day the patient is not limited in fluid intake. Nutrition begins on the 2-3rd day: a special diet of the first days (frequent meals every 2-3 hours in limited quantities; a set of foods from the table of diet 0 is allowed) is gradually expanded by the 6-7th day to 6 meals a day based on diet No. 1a with the exception of dishes made with whole milk.
Postoperative gastric drainage. In the first days of the postoperative period, control intubation of the stomach is performed twice a day. Constant aspiration through a nasogastric tube is indicated for patients with gastric evacuation disorders that have developed in the postoperative period. In this case, the patient is fed through a nasojejunal tube installed endoscopically.
Treatment in the early postoperative period:
- infusion therapy (at this stage it is necessary to completely restore the blood volume and eliminate anemia);
- antiulcer treatment;
- prevention of motor-evacuation disorders (prokinetics are prescribed);
- prophylactic prescription of broad-spectrum antibiotics (due to the threat of infectious complications in anemic patients);
- repeated cleansing enemas to free the colon from altered outflow of blood;
- prophylactic administration of anticoagulants to patients with a high risk of postoperative venous thromboembolic complications.
Physical activity. Movement of the lower extremities, both passive and active, begins immediately after the patient awakens after anesthesia. Starting from the first day of the postoperative period, breathing exercises and acceptable elements of physical therapy are indicated. Getting out of bed is allowed on the 2nd-3rd day of the postoperative period, if there are no contraindications (the severity of the patient’s general condition, the threat of recurrent bleeding from a sutured ulcer, drainage of the abdominal cavity).
Seams removed on the 8-10th day; Patients are discharged taking into account laboratory data indicating the elimination of anemia.

Complications of the early postoperative period

Among the complications after organ-saving operations, it is advisable to highlight those that are directly related to the nature of the intervention - vagotomy and pyloroplasty (with excision and/or suturing of a bleeding ulcer).
These include:

peritonitis, which may be caused by damage to the esophagus during vagotomy, as well as failure of the pyloroplasty sutures;
bleeding into the lumen of the gastrointestinal tract from the pyloroplasty suture line or the area of the sutured vessel in the ulcer;
bleeding into the abdominal cavity (most often caused by damage to the spleen or the vessels accompanying the trunks of the vagus nerves);
postoperative pancreatitis when suturing a vessel at the bottom of an ulcer penetrating into the pancreas; disturbances in gastric evacuation associated with functional changes (decreased tone and motility of the stomach, which often occurs when bleeding is combined with stenosis, as well as in conditions of deep anemia) or mechanical causes (anastomositis and/or technical defects of pyloroplasty).

To prevent the above complications, it is important to comply with all details of the surgical technique, based on knowledge of surgical anatomy, as well as adequate management of patients at all stages of treatment.

Treatment of patients who have suffered ulcerative gastroduodenal bleeding

Outpatient treatment of patients in the postoperative period is based on the principles of medical examination. For the first 2 months (the immediate postoperative period), patients should be under the supervision of a surgeon and a general practitioner (gastroenterologist). The task of this period is to evaluate the effectiveness of the treatment, which is important in determining further treatment measures and predicting results. Important initial indicators may be the results of a study of gastric secretion and the effectiveness of anti-Helicobacter treatment. Evidence of eradication achieved will be negative test results for Helicobacter pylori(morphological and respiratory), carried out after a 4-week cessation of treatment with antisecretory drugs.

Operated patients (first group) continue to receive supportive modern antisecretory treatment. Pathogenetically based surgical interventions themselves guarantee a cure for peptic ulcer disease with a small percentage of undesirable consequences of an organic and functional nature.

Forecast

After organ-sparing operations with vagotomy, before modern pharmacotherapy for peptic ulcer disease, relapses of gastrointestinal tract disease occurred on average in 10% of cases. The use of modern antisecretory drugs for operated patients for certain indications makes it possible to reduce their number. Undesirable consequences of functional operations are, as a rule, mild in nature and do not pose difficulties for drug treatment. Patients who have suffered bleeding of varying severity, undergoing urgent surgery, in the early postoperative period (as well as in the subsequent long-term period) require the supervision of a gastroenterologist.

It is well known from surgical practice that a number of patients who have suffered gastroduodenal bleeding and avoided emergency surgical intervention that was undesirable for them, subsequently require surgical treatment.

Indications for elective surgery:

combined complications of peptic ulcer (bleeding, stenosis of the gastric outlet, deep penetration of the duodenal ulcer into the pancreas);
persistent peptic ulcer and repeatedly recurring profuse gastroduodenal bleeding;
long-term history of ulcers, repeated exacerbations throughout the year, extremely high acid production for an ulcer patient (possible endocrine nature of the ulcer).

When a bleeding ulcer is localized in the stomach, special monitoring of the patient in the postoperative period is necessary due to the risk of possible malignancy of the ulcer.

Yu.M. Pantsyrev, A.I. Mikhalev

Ensure normal evacuation of gastric contents with passage through the duodenum. There are three groups of such operations, which have significant differences: pyloroplasty, gastroduodenostomy and gastrojejunostomy.

Pyloroplasty - an operation to widen the opening between the stomach and duodenum (duodenum) in case of pathological narrowing - is performed to ensure normal passage of food from the stomach to the small intestine.

Pyloroplasty according to Heineke-Mikulicz consists of longitudinally opening the walls of the stomach and duodenum 2 cm proximal and distal to the pylorus and suturing the edges of the incision in the transverse direction.

A longitudinal incision is made along the anterior wall of the stomach and duodenum through a perforated hole. After this, the ulcerative infiltrate is cut off with two semi-oval incisions. At this stage of the operation, the exit from the stomach should be wide open, ensuring that the length of the longitudinal incision along the anterior wall of the stomach and duodenum after cutting off the ulcerative infiltrate is at least 6 cm.

The longitudinal incision of the anterior wall of the stomach and duodenum is converted into a transverse one by traction using the applied suture holders.

To close the incision, a first row of sutures is applied (a continuous suture with a thin thread of catgut through all layers), on top of which a second row is performed. Seromuscular interrupted sutures are applied without strong tissue tension.

At pyloroplasty according to Finney create a wider outlet from the stomach than with pyloroplasty according to Heineke-Mikulich. After applying seromuscular sutures between the anterior walls of the pyloric cave and duodenum, an arcuate incision is made through the pylorus, the lumen of the stomach and duodenum is opened and an anastomosis is formed. Mobilization of the duodenum is performed according to Kocher: the descending part of the duodenum is released by opening the parietal peritoneum along the right edge of the intestine. Interrupted seromuscular sutures combine the greater curvature of the pyloric part of the stomach with the inner edge of the duodenum. The anterior wall of the stomach and duodenum is opened with a continuous arcuate incision, then an anastomosis is formed.

The article was prepared and edited by: surgeon

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Pyloroplasty is a surgical intervention aimed at expanding the pyloric canal by reconstructing it. This operation is performed to facilitate the process of passage of the contents of the digestive canal from the stomach into the duodenum and, as a rule, is prescribed in case of disruption of the innervation of the stomach by the vagus nerves, which developed after vagotomy or separation of the vagus nerves during resection of the proximal stomach and esophagus and restoration of the integrity of these organs.

Essentially, pyloroplasty does not affect the integrity of the gastrointestinal tract. It helps to partially eliminate the antral phase of gastric secretion and reduces the likelihood of the formation of marginal ulcers, which can sometimes be observed after gastrojejunostomy.

From a technical point of view, such surgical interventions are quite simple, therefore they are practically not associated with any serious complications and carry a low level of surgical morbidity and mortality.

Currently, there are quite a large number of methods of pyloroplasty and their various modifications. The main ones among them are the Heineke-Mikulich and Finney methods; less often, doctors turn to the Frede-Ramstedt and Dzhabulei operations. The main requirement for all surgical interventions of this kind is to ensure a 4-5 cm width of the pyloroduodenal canal. These dimensions are determined by the fact that over time, the mouth of the anastomosis gradually narrows due to the natural process of scarring.

Pyloroplasty according to Heineke-Mikulich involves longitudinal dissection of the walls of the stomach and duodenum distal and proximal to the pylorus without opening the mucosa and subsequent suturing of the serous membrane in a direction perpendicular to the cut line (classic version).

When performing pyloroplasty according to Finney, in the same way as when applying the previous technique, a longitudinal incision is made, but it has a significantly greater extent and, if the situation requires it, can be accompanied by excision of the ulcer or part of the pyloric sphincter. The lumen of the stomach and duodenum is always opened here, carefully evacuating the contents of these organs. Forming a V-shaped gastroduodenal anastomosis, the assistant pulls the inflection line of the surgical wound in the area of the pylorus using the thread-holder or the first suture when applying both the posterior and anterior row of sutures. Carefully bringing the ends of the cut closer to each other ensures correct adaptation of the edges of the tissues being connected.

The Frede-Ramstedt method also involves a longitudinal tissue dissection, which involves the seromuscular layer of the pylorus without cutting the mucous membrane. With the Dzhabulei method, the duodenum is dissected in the longitudinal direction, and the antrum of the stomach is dissected in the transverse direction, leaving the pylorus intact.

It should be noted that at the present stage, surgeons practice not only the traditional, open approach to pyloroplasty, but also the laparoscopic one, which can significantly reduce the invasiveness of the intervention and shorten the rehabilitation period for patients.

Gastroduodenoanastomosis according to Zhabula

The essence of gastroduodenoanastomosis according to Zhabula is the mobilization of the duodenum according to Kocher, followed by the imposition of a gastroduodenal anastomosis with a diameter of more than 2.5 cm in a side-to-side manner, bypassing the site of the obstacle. The anastomosis should be located as close as possible to the pyloric sphincter (above the major duodenal papilla). Lateral anastomosis between the stomach and duodenum, as a drainage operation in combination with vagotomy for stenosis, in some cases has an advantage over pyloroplasty.

Technique. In a limited area, the distal part of the stomach at the greater curvature is freed from adhesions so that it can be brought to the anterior surface of the duodenum. After this, the anterior surface of the distal part of the stomach at the greater curvature and the inner edge of the duodenum can be brought together without any tension.

The upper suture is placed immediately below the pylorus, the lower one at a distance of 7-8 cm. The anterior wall of the stomach and duodenum is cut through two incisions without crossing the pylorus. To avoid torsion of the duodenum, the line of its fixation with serous-muscular sutures to the stomach and the line of the incision must be strictly parallel to the vertical axis of the intestine. Then posterior and anterior internal hemostatic sutures are applied with a continuous catgut thread. After this, they begin to apply an anterior outer row of interrupted seromuscular sutures.

Pyloroplasty according to Heineke-Mikulich-Radetzky

The essence of the method is a longitudinal dissection of the antrum of the stomach and the initial part of the duodenum on both sides of the pylorus. To create sufficient lumen of the pylorus, a longitudinal dissection of the walls of the stomach and duodenum should be performed over a length of 3-4 cm, followed by cross-stitching of the resulting wound.

First, the anterior wall of the stomach is opened with scissors at the middle of the distance between the greater and lesser curvature. The contents are removed by suction. The ulcerative infiltrate is excised within healthy tissue using two semi-oval or diamond-shaped incisions. Then the longitudinal incision of the anterior wall of the stomach and duodenum is converted into a transverse one and sutured with a single-row continuous suture through all layers without rough tissue capture, which is completely reliable, eliminates rough tissue inversion, gives a gentle scar and guarantees against cicatricial narrowing of the exit from the stomach.

However, it is also possible to use a double-row suture, when seromuscular interrupted sutures are applied without rough screwing of the tissue.

Pyloroplasty according to Heineke-Mikulich Radetzky with suturing of a bleeding vessel in an ulcer

The operation for profuse bleeding from a duodenal ulcer located on the posterior wall begins with suturing the bleeding vessel. Vagotomy is performed as the second stage of the intervention.

Technique. After revision of the abdominal organs and identification of the source of bleeding, stay sutures are placed on the duodenum along the edges of the anterior semicircle of the pylorus, followed by a wide pyloroduodenotomy. The formed hole is widely stretched in the transverse direction to provide good access to the bleeding ulcer.

To avoid cutting through the callous edges of the ulcer, the piercing ligature should capture healthy areas of the mucous membrane at a distance of 0.5-1 cm from the ulcerative defect and pass under the bottom of the ulcer. Caution must be exercised, keeping in mind the possibility of damage to the common bile duct if the tissue is sutured too deeply.

After this, they proceed to closing the pylorotomy incision. Using stay sutures, the incision of the stomach and duodenum is converted into a transverse one and the wound is sutured according to the method described above. Closing the pylorotomy incision during this operation can also be done with a single-row suture.

Finney's pyloroplasty

Phyloroplasty according to Finney differs from the described method in that a wider outlet from the stomach is formed. This type of pyloroplasty is used for cicatricial ulcerative stenosis of the outlet section, as well as for combined complications of duodenal ulcers when pyloroplasty according to Heineke-Mikulich Radetzky may not provide adequate drainage of the stomach.

Technique. The duodenum is mobilized according to Kocher, the antrum of the stomach and the initial section of the duodenum are dissected with a continuous incision 4-6 cm long. Interrupted seromuscular sutures connect the greater curvature of the pyloric stomach with the inner edge of the duodenum. Sutures are placed on the incision according to the principle of upper gastroduodenal anastomosis, side to side. The upper seam is located immediately at the pylorus, the lower one at a distance of 7-8 cm from the pylorus.

The anterior wall of the stomach and duodenum is dissected with a continuous arcuate incision. After this, a continuous suture is placed on the posterior lip of the anastomosis with an overlapping catgut thread to ensure reliable hemostasis.

The anterior lip of the anastomosis is sutured using a Schmiden screw-in suture from the lower corner of the incision upward towards the pylorus. After this, they begin to apply an anterior outer row of interrupted seromuscular sutures.