RU2014004C1 - Method of forming duodenointestinal end-to-side anastomosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: new method prescribes mobilizing fragment of jejunum without intersecting mesentery, positioning line of seromuscular sutures parallel to mesenteric border of small intestine with crimping duodenal wall, further, transversely incising anterior wall of small intestine to extent of two thirds of its diameter, grasping medial semi-circumference of small intestine wound into through sutures in forming posterior lip of anastomosis and gripping its lateral semi-circumference to form anterior lip of anastomosis. EFFECT: higher efficiency. 3 dwg

Description

 The invention relates to medicine, more specifically to gastrosurgery, and can be used to create an intestinal-duodenal anastomosis in case of gastrectomy and gastrectomy.

 With extensive resections of the stomach and gastrectomy, the operations end with the imposition of an esophageal-enteric or gastrointestinal anastomoses. The disadvantages of this method are due to both the technical features of the operation itself and the disturbances in this process of digestion. Due to the closure of the duodenal stump, duodenal hypertension develops, which is the leading cause of insufficiency of the suture of the duodenal stump and postoperative pancreatitis (Toskin KD Surgery, 1966, N 5, p. 68-73). When the duodenum is excluded from the digestion process, the physiology of digestion is grossly violated. The patient creates unfavorable conditions for the mobilization of compensatory mechanisms with the threat of decompensation. Upcoming painful disorders are clinically manifested in the form of "dumping syndrome." The frequency of this complication reaches 50% (Vilyavin G.D., Berdov B.A. Surgery, 1969. N 1. S. 13-21).

 A technique in which complete or partial removal of the stomach would be accompanied by minimal functional losses compensated by the body has been developed and consists in the use of gastroplasty by replacing the removed organ with a fragment of the small intestine.

 There is a method of replacing the stomach with the small intestine without mobilizing its mesentery, but the end of the duodenum is sewn into the side of the skinny using a conventional longitudinal anastomosis. This operation is not widespread, since it creates conditions for reflux of the duodenal contents into the small intestine transplant and further into the esophagus, which causes severe esophagitis; unregulated intake of food chyme from the small intestine transplant into the duodenum.

 The latter aspect is extremely important, since there is evidence of the possibility of developing a "dumping syndrome" even after the duodenum is included in the digestion process. The pathogenesis of this complication is due to the rapid intake of the food chyme from the intestinal insertion or stomach stump into the duodenum and then into the jejunum (Rusanov A.A. - Vestn. Surgery, 1975, N 10. S. 7-12; Gadzhiev A.S. - Surgery, 1990. N 3. pp. 66-70; Zemlyanoy A.G. - West Surgery, 1990, N 9. pp. 135-137).

 The aim of the invention is to improve the course of the early postoperative period and the prevention of long-term postoperative complications of gastrectomy and resection of the stomach.

 The goal is achieved by replacing the removed stomach or part of it with a fragment of the small intestine without mobilizing and dissecting its mesentery, the formation of an areflux duodenal cone lateral anastomosis, which acts as a pyloric pulp, helps prevent duodenal reflux into the intestinal transplant, and regulates the portioned supply of food chyme to the duodenum includes the pancreato-duodenal zone in the digestive process.

 The technique of the operation is as follows. Upper median laparotomy. After mobilization of the stomach, the drug is removed. Retreating from the Treytz ligament by 10-15 cm, the mesentery of the small intestine is mobilized at a distance of 3-4 cm with the intersection of direct intestinal vessels and the preservation of radial vessels. The small intestine is crossed. After that, the discharge loop of the small intestine is passed through the window in the mesentery of the transverse colon and anastomosed with the esophagus or stump of the stomach. Distal anastomosis 12-15 cm create an anastomosis between the stump of the duodenum and small intestine of the type "end to side" according to the following method. The first suture with a stitch is used to suture the peritoneal edge of the small intestine and the upper edge of the duodenum. A second suture with a stitch is used to suture the peritoneal edge of the small intestine and the lower edge of the duodenum. The distance between the two seams of the holders should correspond to 2/3 of the diameter of the duodenum. Next, stitching of the sero-muscular nodal sutures of the duodenum and small intestine between the previously applied suture holders is performed. In this case, the distance between the screeds on the jejunum should be 1-2 mm less than on the duodenum (Fig. 1). Corrugation of the wall of the duodenum is made in order to give a cone to its initial section. In this case, an excess of the mucous membrane is formed, which turns out of the intestinal lumen in the form of a "rosette". The wall of the jejunum is cut across 2/3 of its diameter. The back and front lips of the anastomosis are sutured with nodal through sutures (Fig. 2). The mucosa of the duodenum is stitched at its very edge. Thus, the mucosa is screwed into the lumen of the intestinal insert. This technique, in combination with a transverse enterotomy, creates conditions that prevent the reflux of bile into the intestinal insert and promotes the formation of artificial pulp in the intestinal-duodenal anastomosis with the regulation of the intake of the food chyme in the duodenum. Next, impose the front row of serous-muscular sutures parallel to the mesenteric edge of the jejunum. At a distance of 1.0-1.5 cm distal to the junoduodenoanastomosis, the lumen of the jejunum is obstructed by a purse string suture, which is covered by nodular gray-serous sutures. A distance between 1.0-1.5 cm between the jejunoduodenoanastomosis and the “plug” allows preventing the deformation of the anastomosis and the formation of a deep blind sac with stagnation of the contents there. Enteroenteroanastomosis of the type "end to side" is applied 1.0-2.0 cm below the "plug". The final view of the enteric-duodenal complex is shown in FIG. 3.

 In addition to the above features, the proposed anastomosis differs from the previously proposed transverse anastomoses in that the external serous-muscular rows of sutures are applied not perpendicular to the longitudinal axis of the intestine, but parallel to it. This is caused by the following reason. During surgery on the stomach, a situation often arises when, after removal of a pathologically altered organ, a very short stump of the duodenum remains. The threat of the development of the failure of the anastomosis imposed with this gut is quite likely. Therefore, the outer row of serous-muscular sutures is imposed on the perpendicular to the longitudinal axis of the intestine, and parallel to it. At the same time, the reliability of the intestinal duodenal anastomosis increases, since the small intestine is freely pulled to a short duodenal stump.

 A gastrectomy followed by gastroplasty was performed in 24 patients operated on for gastric cancer. Observations allow us to conclude that in individuals after gastroplastic surgery the postoperative period was much easier than in patients after conventional gastrectomy. Postoperative complications developed in 4 patients (16.6%). In any case, on the clinical material we had, there were no complications associated with impaired blood supply to the transplant, its atony, motor evacuation disorders, and no fatal outcomes. The application of this technique in the clinic showed that it, not differing from ordinary gastrectomy with the greater complexity and duration of execution, provides a significant improvement in immediate results.

Claims (1)

 METHOD FOR FORMING A TWELVE INTESTINAL ANASTOMOSIS END TO THE SIDE, including mobilization of a fragment of the jejunum without crossing the mesentery, characterized in that, in order to prevent complications by preventing reflux of the duodenal contents into the intestinal transplant, the seroparticulate muscle the duodenum, then dissect transversely the anterior wall of the small intestine into 2/3 of the diameter and with the formation of the posterior lip of the anastomosis into the through seams Attach the medial semicircle of the wound of the small intestine, and with the formation of the anterior lip of the anastomosis, its lateral semicircle.

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