PYLOROPLASTY (grech, pyloros the gatekeeper + plastike sculpture, plastics) — operation of a section or excision of the site of the gatekeeper with the subsequent sewing up of the defect formed in the peloric channel.
Liquidating switching function of the gatekeeper, P. provides drainage of antral department stomach (see). It is applied usually after trunk or selection vagisection, a cardiectomy, anti-reflux stomach operations.
Indications and Contraindications
Indications: the ulcers of a duodenum or the gatekeeper complicated by profuse bleeding, perforation, a stenosis of output department of a stomach, especially at advanced age or at serious associated diseases when the main operation is vagisection in various options; at chest age — an inborn pylorostenosis.
Contraindications: the expressed disturbances motor evakuatornoy functions of a duodenum, hron, the duodenal impassability, big ulcer infiltrates occupying a front semi-circle of a duodenum.
P. usually carry out under the general anesthesia.
Apply two simplest and reliable modifications of P. more often — across Geyneka — to Mikulich and across Finney. At the perforative and bleeding ulcer of a front wall of a duodenum of P. make excising an ulcer according to Judd — a so-called front gemipilorektomiya. At an inborn pylorostenosis of P. make by an extramucosal pylorotomy according to Freda — to Ramshtedt.
Pyloroplasty across Geyneka — to Mikulich (fig. 1). The gatekeeper determine by a peloric vein and palpatorno. On a duodenum at the edges of a front semi-circle of the gatekeeper impose seams handles, to-rye at the same time alloy a peloric vein. A section 6 cm long cut a front wall of the peloric channel equally spaced in both parties from the gatekeeper. The formed longitudinal opening in a wall is translated in cross by traction for seams handles. Through all layers put a continuous suture, and then the second row of noose serous and muscular sutures. In order to avoid narrowing of an anastomosis it is more reasonable to sew at first only a mucous membrane of a stomach and a duodenum or sometimes to close a pilorotomi-chesky opening one number of noose sutures.
Pyloroplasty across Finney (fig. 2) is an optimum method of the operation draining a stomach, especially at a cicatricial and ulcer stenosis of output department of a stomach. In order to avoid a tension of seams the duodenum will be mobilized on Kokhera. Noose serous and muscular sutures big curvature of peloric department of a stomach is sewed with medial edge of a duodenum. The upper seam is located at the gatekeeper, lower — at distance of 7 — 8 cm from it. Then the front wall of a stomach and duodenum is cut the arc-shaped section and a continuous suture which is carried out through all layers of a stomach and a gut, sew walls of an anastomosis — at first back, and then and a lobby, peritonizing it noose serous and muscular sutures.
Pylorotomy according to Freda — to Ramshtedt (fig. 3). Make a transrectal laparotomy in right hypochondrium. The Pilorichesky department of a stomach together with the reinforced gatekeeper is removed in a wound. In an avascular zone make a slit of serous and muscular layers of the gatekeeper. Edges of a muscle stupidly part to a prolapse of a mucous membrane. At accidental wound of a mucous membrane defect is taken in an atraumatic needle.
The postoperative period
the Postoperative period at adults has no features. After P. made concerning an inborn pylorostenosis, feeding of the child (5 — 10 ml of breast milk) is begun in 4 — 6 hours after operation. In the first days in addition parenterally enter glucose, reopoliglyukin, plasma, albumine. At a favorable current and a resistant increase in the weight of the child write out home on 9 — the 10th days after operation.
Funkts, disturbances after P. (see. Postgastrorezektsionny syndrome ) it is observed considerably less than after a resection of a stomach. The recurrence of a peptic ulcer celebrated on average at 6 — 8% of patients after P. and vagisection can be connected with incomplete vagisection or inadequate drainage of a stomach, cicatricial narrowing of area P.
the X-ray pattern after a pyloroplasty
After P. the wide gastroduodenal channel is determined by Geyneka — to Mikulich, in Krom it is impossible to differentiate a zone of the former peloric press and a bulb of a duodenum. The channel is in a condition of constant disclosure, sphincteric activity in it is not found. Contrast weight due to the lack of the sphincteric mechanism quickly and comes large portions from a stomach to a duodenum. In the channel there are psevdodivertikulyar-ny protrusions of a different form and depth (fig. 4), typical for P. on this modification. Diverticulums in the course of the research change the outlines and the sizes and can be exempted from contrast weight completely. Sokratitelny activity of antral department is a little reduced, especially if P. was combined with vagisection. The change of contours of a proximal part of a duodenum caused by its cicatricial deformation is quite often observed. Rentgenol, control of healing of a piloroduodenalny ulcer or identification of a recurrence of an ulcer in this zone are complicated because of its divertikuloobrazny deformation. Sometimes accumulation of barium in a diverticulum makes a false impression of ulcer «niche», however unlike true «niche» the diverticulum changes the sizes and a form in the course of the research.
After P. across Finney the wide anastomosis between antral department and a proximal part of a duodenum is formed. Pseudo-diverticulums are observed less often, evacuation from a stomach is accelerated.
At X-ray inspection of a stomach at the children operated by a method to Freda — Ramshtedta, in the remote terms after operation the X-ray pattern of a piloroduodenalny zone does not differ from normal, the prolapse of a mucous membrane of a stomach in a duodenum is sometimes observed.
Bibliography: Izakson V. B. A condition of piloroduodenalny area of a stomach according to a clinicoradiological research in the remote terms after surgical correction of an inborn pylorostenosis, Works Mosk. Region nauch. - issled. wedge, in-that (MONICA), t. 9, page 124, 1975; Pantsyrev Yu. M. and Greenberg A. A. Vagisection at the complicated duodenal ulcers, M., 1979; P e of t to e in and G. V.'s h and Socks A. P. Motor and evakuatorny function of digestive tract at children in the remote terms after a pylorotomy according to Freda — to Ramshtedt, Vopr. okhr. mat. also it is put., t. 24, No. 4, page 42, 1979; Shalimov A. A. and Saenko V. F. Surgery of a stomach and duodenum, page 101, Kiev, 1972; Bloch C1. Wolf of V. The gastroduodenal channel after pyloroplasty and vagotomy, Radiology, v. 84, p. 43, 1965;
S a p o u-n o v St. Das Rontgenbild von Speise-rohre, Magen und Zwolffingerdarm nach selektiver gastraler Vagotomie und Pyloro-myoplastik, Fortschr. Rontgenstar., Bd 115, S. 423, 1971; Zollinger R. M. a. Zollinger R. M. Jr. Atlas of surgical operations, N. Y., 1975.
A. A. Greenberg; T. V. Krasovskaya (it is put. hir.), V. V. Kitayev (rents.).