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13
III. ХИРУРГИЯ
UDC 616.33-002.44:616.342
ABOUT THE AUTHORS
Abdullaev D.S. - associate professor of Department. Hospital Surgery Kyrgyz State Medical Academy, can., med. Head sector NHTS MOH, Honored Doctor of the Kyrgyz Republic;
Alybaev E.U. - Professor of the Department of Hospital Surgery Kyrgyz State Medical Academy, head of the Ministry of Health NHTS. Doctor of Medical Sciences.
Keywords:
Arterio mesenteric duodenal compression (AMDC), gastric ulcer (GU), X-ray diagnostic, tubeless and probe hypotonic duodenography with double contrast study, endoscopy, ultrasonic examination, transverse duodenojejunostomy, Treitz ligament transection, pylorus preserving gastric resection
АВТОРЛАР ТУРАЛЫ
Абдуллаев Д.С. - КММА, госпиталды хирургия кафедрасынын доцентi, KP ДСМ YXO секторынын менгеруш1С1,м.г.к., KP енбекп сщген дэрiгерi;
Алыбаев Э.У. - КММА, госпиталды хирургия кафедрасынын проессоры, KP ДСМ YXO секторынын менгерушiсi,м.r.д.
Туйш сездер
Ултабардын артериомезен-териалды компрессиясы, асказаннын ойыкжарасы, квлденен антиперистальстатик дуоденоеюностомия, рассечение связки Трейтц байламда-рын жару, асказаннын карын какапасын сактайтын резекция.
ARTERIO MESENTERIC DUODENAL COMPRESSION IN CONJUNCTION WITH GASTRIC ULCER, DIAGNOSTIC AND SURGERY TREATMENT
Abdullaev D.S., Alybaev E.U., Sydygaliev K.S., Alybaev M.E.
Kyrgyz State Medical Academy, the National Surgery Center of the Ministry of Health of the Kyrgyz Republic. Bishkek
Summary
The analyze of the surgery treatment results has been conducted for 300 patients with AMDC in conjunction with GU. There were 215 in the control group and 85 in the main group. The Treitz ligament transection has been performed if there was the compensated stage of the AMC. If AMC were in sub- and de-compensated stages the duodenojejunostomy were performed. The Gastric resection on Billroth I with preserving the pyloric sphincter were performed if gastric ulcer.
Артериомезентериалды компрессия асказанньщ ойьщжара ауруымен араласуы, оны диагностикалау жэне хирургиялык емдеу
Абдуллаев Д.С., Алыбаев Э.У., Сыдыгалиев К.С., Алыбаев М.Э.
К,ыршз Мемлекетш медицина академиясы,
К,Р Денсаулык, сак,тау министрлИнщ Улттык, хирургиялык, орталыш, Бшкек к,.
Ацдатпа
АОЖ аралас АМК шалдыккан 300 аурудын хирургиялык емдеу'ш'щ талдауы журпз¡щ1. Бакылау тобын-да 215 аупу жэне непзп топта 85 ауру зерттелдi. АМК кезiнде втелген кезенде ТРС втюзшген. АМК кезiнде суб- жэне втелгенге дейшп кезец'шде вДКк±рыл€ан. АОЖкезiнде АКСР-мен БильротI бойын-ша асказаннын резекциясын жасады.
ОБ АВТОРАХ
Абдуллаев Д.С. - доцент каф. госпитальной хирургии КГМА, зав. сектором НХЦ МЗ КР, к.м.н., заслуженный врач КР; Алыбаев Э.У. - профессор кафедры госпитальной хирургии КГМА, заедующий сектором НХЦ МЗ КР, д.м.н.
Артериомезентериальная компрессия в сочетании с язвенной болезнью желудка, диагностика и хирургическое лечение
Абдуллаев Д.С., Алыбаев Э.У., Сыдыгалиев К.С., Алыбаев М.Э.
Кыргызская Государственная Медицинская Академия,
Национальный Хирургический Центр Министерства Здравоохранения КР, г. Бишкек
Ключевые слова:
Артериомезентериальная компрессия двенадцатиперстной кишки, язвенная болезнь желудка, поперечнаяая антиперистальтическая дуоденое-юностомия, рассечение связки Трейтца, пилоруссохраняющая резекция желудка.
Аннотация
Проведен анализ результатов хирургического лечения 300 больных АМК в сочетании с ЯБЖ. В контрольной группе было 215 и в основной 85 больных. При АМК в компенсированной стадии проводили РСТ. При АМК в суб- и декомпенсированной стадии создавали ДЕС. При ЯБЖ проводили РЖ по Бильрот I с ПСРЖ.
Introduction
The arterio mesenteric duodenal compression (AMDC) is referred in the literature as a Wilkie syndrome, or the superior mesenteric artery syndrome or the arterio mesenteric compression syndrome [1]. The possibility of duodenum compression by crosses its superior mesenteric artery (SMA) firstly was mentioned by Carl Freiherr von Rokitan-sky, Austrian professor, in his educational book of anatomy in 1842. Subsequently, in 1927 Wilkie was a first who comprehensively studied a group of 75 patients, and then the superior mesenteric artery syndrome was named by his name [2].
AMC is a common pathology and according to different authors in the structure of all GI tract pathologies it can be found in 0.09-2.5% of patients, and in the general population - within 0.013-0.3%, that confirmed by X-ray.
The AMC is based on vascular compression of the lower horizontal part of duodenum between superior mesenteric artery from one side and the aorta and spine from other side [3,4,5]. In most cases, the formation of AMDC is a complication of gastric ulcer (GU) and duodenal ulcer (DU) [6]. The clinical signs of the AMC and peptic ulcer disease are very similar, that creates difficulties in their differential diagnosis, especially if there is a complicated course.
The examination methods. Along with clinical manifestations, there are instrumental examination methods for AMC: X-ray diagnostics [7, 8]. endos-copy, ultrasound examination (US), duodenum ma-nometry, CT, MRI and others [4]. When the AMC, the radiograph shows the compression of lower horizontal part of duodenum, respectively to the projection of the superior mesenteric artery. It is a short (1.5-2.5 cm) with a clear smooth oral contour or with a bluff line of chyme evacuation. In the zone of compression the mucosal folds are longitudinally rebuilt. V.L. Martynov et al. (9) recommend to diagnosing the AMC integrated and phased with tubeless and relaxation duodenography probe with double contrast. The Fiberoptic esophagogastro-duodenoscopy (FEGDS) is allowed to detect the gastric fasting content, the degree of duodenogas-tric reflux (DGR), the pylorus incompletely opening, as well as detect erosions and ulcers localization. [10]. A. Mansberger and J. Hearn [11] by carrying out the arteriomesentericography with simultaneous contrasting of duodenum show that in normal the angle between SMA and aorta is around 45-60°, and for the patients with AMC in the lower horizontal part of duodenum - 10-20°. The normal distance between SMA and aorta (AMD) in the area of crossing the duodenum is 7-20 mm, and 2-3 mm for the patients with AMC. The Ultrasound examination is
wide using for diagnosing the AMC [12]. The US-examination can diagnose the AMC by detecting AMA and AMD. The Hydroultrasound examination of gaster and duodenum allows to improve the visualization of gaster. Then the duodenum examination is carrying out.
Most of the abdominal surgeons believe that AMC is requiring surgery treatment. All surgical treatments of the AMC divide into two groups: first - interventions that keep food transit through duodenum, second - interventions that exclude the duodenum from digestion. The first group interventions are directed to drain of the duodenum by overlapping the duodenojejunostomy (DES) or by separation of commissures and ligamentous apparatus of intestinum [13]. Y.D. Vitebskiy [14] recommends surgery on imposing the transverse antiperistaltic duodenojejunostomy (TADES). In recent years, there are used the methods on laparoscopic treatments of the AMC [15]. These are laparoscopic ligament of Treitz transection and laparoscopic DES [16, 17].
The surgeries with excluding the duodenum from digestion include: gastrojejunostomy, gastric resection on Billroth II, gastric resection on Roux [18] and its modifications. There are also conducted combined operations on the stomach and duodenum, combination the gastric resection with DES, bilateral exclusion of duodenum with DES.
Many surgeons refuse gastric resection on Billroth I to the patients with GU combined with AMC. Removing the pyloric part of stomach with preservation of duodenal chyme passage leads to increasing frequency and intensity of the duodenogastric reflux. In order to exclusion food passage through duodenum for the patients with gastric ulcer with AMC there is used gastric resection on Billroth II. In this case such operation does not remove the cause of the AMC, and moreover can lead to worse condition because there can be formed afferent loop syndrome [10], bile reflux gastritis. In remote postoperative periods more than 50% of operated patients can have unsatisfactory results [10].
Material and methods: The control group of 215 patients with gastric ulcer in conjunction with AMC included 161 (74.3 %) males and 54 (25.7 %) females. 141 (78.8%) of them were with compensated stage of the AMC, 52 (21.2%) with subcompensated and 22 (10.2%) patients with decompen-sated stage. There were 85 patients with gastric ulcer in conjunction with AMC in the main clinical group - 71 males (83.5%) and 14 females (16.5%). In the main clinical group 57 (67%) patients were with compensated stage of the AMC, 21 (24%) with subcompensated stage and 7 (5.9%) with decom-pensated stage.
In the main group, included 85 patients, the most frequent complication of gastric ulcer were ulcer bleeding - 32 (37.6%), second place - penetration of ulcers - 19 (22.4%), third place - pyloroduo-denal stenosis - 18 (21.2%). Fourth place among the complications was the ulcer perforation - 16 (18.8%). In the anamnesis of 17 (20.0%) patients was bleeding and 10 (11.8%) had suture plication after perforation of ulcer.
All patients underwent a comprehensive instrumental examination: due to the low availability for the most of patients the computerized tomography and MRI these examinations were not conducted.
Discussion
Indications for surgical treatment of GU become more compelling when the gastric ulcer combined with duodenal ulcer [20], recurrent ulcer, perforations and bleeding in anamnesis or in the present [9]. Typically, emergency operations are carrying out for such patients. Specific course of the GU and especially the possibility its malignancy makes it necessary to perform surgery treatment as an elective operations.
According to our work, for the patients with AMC + GU the elective operations were performed for 56.4%, emergency surgery performed for 43.6% of patients. Among all 85 operated patients for 42 (49.4%) was performed the gastrectomy Billroth I + TADES, for 15 (17.6%) - gastrectomy Billroth II + TADES, 10 (11.8%) - gastrectomy Billroth I + TADES + fundoplication, 8 (9.4%) - gastrectomy Billroth 1 + ligament of Treitz transection, 6 (7%) - gastrectomy Billroth I + duodenoliz, 4 (4.7%%) - gastrectomy Billroth I + fundoplication + ligament of Treitz transection. The Gastrectomy Billroth I was performed with preservation of the pyloric sphincter.
The Billroth II gastrectomy has been performed when there was not possible to preserve the pyloric sphincter at the pyloroduodenal stenosis. The combination GU with AMC in subcompensated or decompensated stages the gastrectomy resection performed together with TADES that was made for 67 (78.8%) patients. When combined with compen-
Fig. 1
TADES operation with closing the efferent duodenum loop
sated AMC there was carried out the made the Treitz ligament transection or duodenoliz, which were performed for 18 (21.2%) patients. For 4 (4.7%) patients with gastroesophageal reflux disease (GERD) were simultaneously performed Nissen fundoplica-tion.
We agree with the authors [8,20], that gastrectomy Billroth I with preservation of the pyloric sphincter is allowed to exclude the duodenogas-tric reflux, and using the TADES preserves the natural passage of chyme through duodenum. The studies made by A.A.Shalimov 1963 and Maki, 1964 [21] contributed to widespread use of gastrectomy on Billroth I with preservation of the pyloric sphincter. The Treitz ligament transection [22], as an independent operation, almost is not applied, and we agree with the opinion that it should be mandatory component of gastric resection when there is a compensated stage of the AMC or distal perijejunitis. The TADES performed when there were subcompensated or de-compensated stages of the AMC.
After applying duodenojejunostomy in some patients in the postoperative period may be caused functional disorders of duodenal patency as feeling of heaviness in upper abdomen, nausea, or bile vomiting. These signs are evaluated as gastrostasis, du-odenogastric reflux, anastomositis. As the duodeno-jejunostomy provides retaining the intestinal «ring», the part of chyme evacuates through duodenum, and its retrograde motion through the anastomosis leads to forming «vicious circle» syndrome (3).
In order to prevent developing the syndrome of «vicious circle» we have developed a «Method duodenojejunostomy at the AMC», Patent No 832. - Bishkek - 2005. After applying the TADES we create a «cap» of the efferent duodenum loop from a part of the greater omentum leg. A flap with supply vessel is cut from the greater omentum, the tip of which is divided into two flaps and circularly envelops duodenum as a cuff step distal up to 2-3 cm from duodenojejunostomy, and narrowing the intestine lumen up to it complete closing. The ends of the flap fix to each other. So we prevent developing the syndrome of «vicious circle» (Fig. 1).
Analysis of the postoperative complications of patients with AMC in conjunction with GU showed that in the control group the pancreatitis has been developed in 11 (5.1%) patients, while in the main group there was only 2 (2.3%) causes; anastomositis has been developed in 10 (5.1%) in the control group, and in the main group - 2 (2.3%). The clinical signs of the gastrostasis has been developed in 6 (2.8%), and 1 (1.2%) in the main group. We believe that this is a result of applying the operation TADES with closing the efferent duodenum loop by our method.
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Conclusions
1. In order to diagnose and assess the severity of the patients with AMC in conjunction with GU there should use all available methods of instrumental examinations.
2. The method of choice for surgical treatment of the AMC in conjunction with GU is gastrectomy with Billroth I with preserving the pyloric sphincter, TADES with closing the efferent duodenum loop from a flap of the greater omentum in order to prevent formation the syndrome of «blind sac»
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