Prophylaxis of damage of extrahepatic biliary ducts and pancreatic ducts while performance of gastric resection in accordance to Billroth II method for complicated duodenal ulcers
Objective. To elaborate a method of mobilization and a method of closure of “complex handed” duodenal stump while operating for complicated giant penetrating pyloroduodenal ulcers with the aim to prevent iatrogenic damage of extrahepatic biliary ducts and pancreatic ducts and to improve the results of surgical treatment of this pathology.
Materials and metods. In the investigation 46 patients were included, who were operated on for complicated giant penetrating pyloroduodenal ulcers. Giant pyloroduodenal ulcers have had more than 2.5 cm size. The method of duodenal mobilization and the method of suturing of a “complex” duodenal stump were proposed. The method of duodenal mobilization consists of duodenotomy in the zone of a cicatricial-ulcerative transformation and intraintestinal digital upper and anterior stretching towards yourself of all duodenal walls from adhesive process, what includes mobilization of upper-horizontal and of part of descending duodenum portiions, using incision of visceral peritoneum along right and left edges of colon on a distance, sufficient to form its stump without tension. The method of suturing of a “complex” duodenal stump consists of duodenotomy in the affected zone of circular ulcer process. This permits to determine a degree of ulcerative stenosis, to exterritorize the ulcer and after duodenal mobilization, using the above mentioned method, to apply the duodenal mobilized walls for formation of a stump. Application of a one-raw interrupted screw-up sutures permits to distribute the pressure load along all sutures what enhances a mechanical strength of the sutures placed.
Results. Average duration of the operation have constituted 136.6 min (95% CI: 125.2; 152.0); a stationary stay - from 7 to 26 bed-days, 15.7 days (95% CI: 13.1; 18.2) at average. Among early postoperative morbidity there were: infection in the wound zone - 2 (4.3%), pneumonia (4.3%), stroke - 1 (2.2%), pulmonary thromboembolism - 1 (2.2%), insufficiency of the duodenal stump sutures - 1 (2.2%) observation. Postoperative mortality have constituted 4.3%, 2 patients died, in 1 (2.2%) pulmonary thromboembolism was the cause of the death, and in 1 (2.2%) - hemorrhagic insult. The duodenal stump sutures insufficiency and extensive serous-fibrinous peritonitis were revealed in the patient on the 6th postoperative day in 1 (2,2%) patient. In 1 year 31 patients were examined: while performing of fibrogastroscopy in 1 (3.2%) patient the ulcer of posterior wall of gastrojejunoanastomosis was revealed, in 7 (22.6%) - superficial gastritis, in 1 (3.2%) - erosive gastritis of gastric stump.
Conclusion. The proposed procedure for duodenal mobilization and the method of the duodenal stump formation in a complicated giant circular pyloroduodenal ulcer permits to minimize a possibility of the stump sutures insufficiency occurrence as well as the prevention of iatrogenic damage of biliary and pancreatic ducts, involved in the ulcer infiltrate, injury, and may be recommended for application in clinical practice. Special attention must be drawn to duodenal decompression in postoperative period and to intestinal stimulation.
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