Errors in the treatment of duodenosis

April 20, 2018 04:15 | Symptoms And Treatment
One of the mistakes in the surgical treatment of our patients suffering from duodenal stasis was the separation of adhesions detected in the course of the duodenum, which were found guilty of impaired bowel movement. However, as shown by the results of a second study of patients after such an operation, their condition did not improve. Most of them had to re-operate due to persistent signs of duodenal stasis. As noted earlier, we consider it erroneous in all cases of duodenal stasis to apply duodenojunoanastomosis as a side-to-side type without considering the cause and stage of motor dysfunction of the duodenum. In addition to these erroneous actions, in 5 patients gross mistakes were made in operational tactics. Among them, one patient with a pronounced clinical picture of motor dysfunction of the duodenum did not take into account the sharp atony and ectasia of the intestine, and the operation was completed by the creation of gastroenteroanastomosis. After the operation, the patient's condition continued to worsen, and she died as a result of an ongoing violation of the patency of the duodenum. We give an observation.

Patient D., 60 years old, considers himself ill about 2 years old, when he began to worry about dyspeptic disorders. Recently, the condition deteriorated significantly: vomiting appeared, and the patient began to progressively lose weight. The condition is heavy. The patient is weak, adynamic, exhausted. The abdomen is painful in the epigastric region, the liver protrudes from the hypochondrium. The conclusion of the radiologist: hypotension and ptosis of the stomach, ectasia of the duodenum, stenosis of the descending part of the duodenum, apparently, of an organic nature. During the operation of the abdomen, it was found that the stomach and duodenum are considerably stretched, flabby. In the area of ​​the gatekeeper, an indistinct compaction. Gastrotomy. The channel passes the finger. Anterior gastroenteroanastomosis is applied. After the operation, the patient's condition remains weak, vomiting continues. When fluoroscopy for 40 minutes after taking barium failed to detect the filling of the duodenum. Despite the ongoing treatment, the patient's condition progressively worsened, and she died.

At autopsy: a sharp ectasia of the stomach and duodenum. In the stomach are the remains of barium. The mucous membrane of the stomach and duodenum is cyanotic. There were no local organic changes in them. Gastroenteroanastomosis is passable. Death was due to exhaustion and intoxication.

In a second patient with acute course of violation of patency of the duodenum during an emergency operation, significant ectasia of the stomach and duodenum was revealed. During the operation, they limited themselves to puncturing the stomach and evacuating its contents and the contents of the duodenum. This led to the elimination of only signs of acute obstruction and a temporary improvement. However, later the patient continued to worry with bouts of pain and periodically vomiting with bile. X-ray examination revealed duodenal stasis with ectasia of the intestine.

The operational tactics were also erroneous in the third patient, with a clinical picture of peptic ulcer combined with duodenal stasis. In the operation, he also revealed ectasia of the initial loop of the jejunum. Not having determined the touch of an ulcer, the surgeon limited to imposing an anastomosis on the type of side to side. The operation did not bring relief to the patient. In view of the ongoing pain and dyspeptic disorders, the patient was operated on again, and he underwent a stomach resection according to Billroth II.However, this time the presence of an ectatic and edematous initial loop of the jejunum was not taken into account. After the second operation, vomiting was repeated, and the patient was again subjected to surgery - resection of the stomach and the initial loop of the jejunum for 50 cm( because of its ectasia and atony), followed by the formation of a y-shaped anastomosis according to Ru. After this operation, vomiting stopped, and a clinical recovery came.

One patient( with past gastroenteroanastomosis for duodenal ulcers) during the second operation( due to recurrence of peptic ulcer) had signs of duodenal stasis in the form of considerable ectasia and atony of the duodenum. However, this condition of the gut was not taken into account. The stomach was resected to the place of gastroenteroanastomosis. Discharge of the duodenum was not performed. In the postoperative period, the patient developed persistent vomiting with an admixture of bile, which was why she had to operate again in an emergency. With relaparotomy, it turned out that the reason for stubborn vomiting was a poorly emptying duodenum. After the formation of the anastomosis, recovery came.

Erroneous operational tactics were made in one patient operated on for repeated attacks of pancreatitis with an established roentgenologic and confirmed hypotonic duodenal stasis during surgery. Despite such a diagnosis, anastomosis was applied to discharge the biliary tract. After the operation, the patient's condition did not improve. She was still harassed by bouts of pain. The patient is transferred to a disability.

These observations indicate the importance of taking into account the motor-evacuation function of the duodenum when deciding on operational tactics. Violation of this rule leads to unfavorable results and requires a second operation.