RU2069539C1 - Method for preventing complications in making gastroduodenal anastomosis after gastrectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves mobilizing esophagus in inferothoracic region before its dissecting from the cardiac part of the stomach. Vital capacity of the esophagus is controlled by means of electromyography. The esophagus is brought down to the level of hepaticoduodenal ligament. EFFECT: prevented complications.

Description

 The invention relates to medicine, in particular to surgery, and can be used in surgical departments where operations are performed on the stomach.

 Recently, many variants of anastomoses for gastroectomy have been developed. Almost every one of them has certain disadvantages, which determines a consistently high percentage of postoperative complications, mostly due to the nature of the formed anastomosis, as well as the frequency of the so-called post-resection syndromes.

 For the first time, the successful implementation of esophagojejunostomy during extirpation of the stomach was performed by Schlatter in 1897. A year later, during a similar intervention, the continuity of the digestive tract was restored by means of an esophageal-duodenal anastomosis (Brigham, 1898). It would seem that an attractive attempt not to exclude the duodenum from digestion found few supporters due to the significant tension of the sutures and the high incidence of anastomosis. For a long time, esophageojejunanastomosis with interintestinal anastomosis was the most successful, which is largely due to the ease of bringing the jejunum loop to the abdominal esophagus without the threat of impaired blood supply to the anastomosed segments. Gradually, experience was accumulated of the negative consequences of this type of intervention, among which there were dumping syndrome, afferent loop syndrome, anastomosis structure, development of reflux esophagitis, significant asthenization of operated patients, development of anemia, postoperative pancreatitis, etc.

 Given the achievement of a better quality of life in people who had an anastomosis with the jejunum loop turned off along the Ru, this technique was widely used. The advantages of this anastomosing technique were so undeniable in connection with the rare events of one of the most serious consequences of the complete removal of the stomach of reflux esophagitis. At the same time, a number of researchers on a large statistical material showed that the risk of insolvency of such an anastomotic variant is not lower, but higher than in the case of using a conventional esophageal syndrome.

 With all the categorical conclusions about the results of the formation of various methods of anastomosis between the esophagus and the small intestine, which is present in most works, there is a practically unanimous difference in the relationship between the passage of food and the duodenum. Switching off the latter sharply increases the likelihood of dumping syndrome, the severe degree of which corresponds to complete disability of patients. In addition, the adequate activity of the most important digestive glands, the inclusion of complex hormonal mechanisms of the duodenum implies the predominant restoration of the duodenal passage by one or another of the methods.

 It seems natural that researchers strive to preserve the natural relationships of various segments of the digestive tract to the maximum extent, which implies a significant reduction in surgical trauma; this is important for this category of debilitated patients. Such "physiological" techniques for applying the esophageal-enteric anastomosis include the methods of Nakayama (1956).

 The elimination of one or more protective mechanisms during gastroectomy, which prevents the reflux of intestinal contents in healthy individuals, makes a real threat to the esophageal mucosa. An exception may be considered methods of forming artificial pulp (using the legs of the diaphragm, etc.), the theoretical advantages of which do not require substantiation.

 As a prototype, the method of anastomosis of the esophagus and duodenum was selected, which prevents the pronounced phenomena of dumping syndrome and some other digestive disorders due to the fact that the duodenum did not turn off from the passage of food. Moreover, to compare the segments of the digestive tract, the duodenum was mobilized according to Kocher.

 The purpose of the invention is the development of a method for the prevention of post-gastrectomy complications by forming a direct esophageal-duodenal anastomosis, which maintains the unchanged state of the duodenum as a regulator of digestive activity, contributing to the prevention of retrograde entry of intestinal contents and ensuring sufficient reliability and tightness of the sutures.

 The goal is achieved in that during the formation of a direct esophageal-duodenal anastomosis, the length of the abdominal segment of the esophagus is increased by mobilizing it while maintaining the natural position of the duodenum.

 The method is as follows.

 Before cutting off the abdominal esophagus from the cardiac section of the stomach, the latter is mobilized in the lower thoracic section while maintaining blood supply within the required limits, which is controlled by intraoperative registration of the bioelectrical activity of the mobilized section. The specified manipulation is carried out by a clothespin electrode; in the process of mobilization, the abdominal esophagus is reduced to the level of the location of the hepatoduodenal connection.

 Before removal of the stomach, vascular atraumatic pulp of the Sotinsky type is applied to the duodenum and esophagus to minimize compression of the stitched segments. Comparison of the pulp allows you to check the absence of tension. Subsequently, atraumatic sutures are applied with a thread with a conditional number 4/0 on the posterior lip of the anastomosis (the outer row with the capture of the serous-muscular and muscle layers of stitched segments, the use of microtechnical elements, nodal sutures; the inner row is mucous-submucous nodal sutures according to the same principles) after which a series of nodal screwing sutures is applied behind the mucous-submucosal layer on the front lip and the outer row of sutures according to the aforementioned technique.

Distinctive features of the proposed method from the prototype are:
preservation of the natural position of the duodenum, which leads to the absence of a damaging effect on the motor activity of the digestive tract included in the passage of the chyme, but not mobilized according to Kocher intestine;
an increase in the length of the abdominal esophagus, which is one of the main factors of protection against reflux.

 All of the above can reduce the risk of developing post-gastrectomy disorders and prevent the possibility of postoperative complications, including in connection with sufficient tightness and reliability of the anastomosis.

 Example 1. The medical history N 284. Patient S. 75 years. The operation (09.01.91 g.), The abdominal cavity was opened by upper midline access 25 cm long. Diagnosed with a lesion of the stomach by a tumor. There are no distant metastases. Subsequently, a gastrectomy was performed with ligation of the left gastric artery at the place of discharge from the celiac trunk and mobilization of the lower thoracic esophagus, which allowed to lower the distal segment of the latter to the duodenum without tension of the organs being compared. After diaphragmotomy, the integrity of the pleural cavities was restored with the help of nodal sutures on tissue dissected before mobilization of the esophagus. Atraumatic vascular pulp was superimposed on the intersected sections of the esophagus and duodenum, which are easily matched and nodal sutures are started with microtechnical elements with a 4/0 thread sequentially between the serous-muscular and muscle case, the mucous-submucosal row (posterior and anterior lip, the latter in the screw-in wound) ), again between the serous-muscle and muscle layer of the compared segments. The viability of the distal esophagus has been proven in the process of electromyography with a clothespin electrode using the bipolar method. The postoperative period was uneventful. In the course of manometric studies, the preservation of the activity of the small intestine was revealed, there were no signs of postoperative pancreatitis. On the third day, the gases departed, the patient began enteral feeding, which was not accompanied by dyspeptic phenomena. Also exacerbation of chronic lung diseases was not detected; by the 14th day, during electromyography of the small intestine, restoration of the myoelectric mobile complex was detected. Discharged on the 20th day.

 Example 2 (prototype method). Patient B., 52 years old, medical history N 2034. Operation (03/21/90), supra-median laparotomy. A resectable tumor of the stomach without distant metastases was revealed. After mobilization of the stomach with a ligamentous apparatus, a gastrectomy was performed, the duodenum was mobilized and an esophageal-duodenal anastomosis was applied without tension according to the Priestley and Kumpuris method. The anastomosis is passable. Layered seams on the wound.

 In the postoperative period, from the 5th day, the patient appeared and began to steadily progress the phenomenon of pancreatitis. Despite active measures to combat pancreatic autolysis, the patient persistently maintained signs of paresis of the digestive tract, on the 20th day, the melting of the duodenal wall was detected. Until 35 days, probe feeding continued; fistulas independently closed, the patient was discharged for outpatient treatment 1.5 months after the intervention. When floor manometry in the specified time revealed dysfunction of the duodenum, dysfunction of the lower esophageal sphincter.

Proof of the effectiveness of the proposed method are:
1. The formed anastomosis can significantly reduce the frequency and severity of the most common negative consequences of gastric removal (compared with the prototype) of dysphagia from 41.8 to 0 reflux esophagitis from 58.6 to 20 diarrhea from 10.3 to 0 dumping syndrome with 13.8 to 0 Significant differences are due to the preservation of the function of the duodenum with portioned food intake, adequate activity of the most important digestive glands, the preservation of the front of activity migration from the pacemaker zone and the coordination of motility of the lower esophageal sphin Tera, sphincter of Oddi and the duodenal bulb, which is confirmed in long-term period in the study of the suction performance, the motor and the bioelectric activity of the intestine, as well as the results of X-ray and endoscopy in 21 operated by the method described patients.

 2. The method allows to achieve the necessary reliability and tightness of the anastomosis to reduce the risk of failure of the joints.

Claims (1)

 A method for the prevention of complications when applying a direct esophageal-duodenal anastomosis after gastrectomy, including mobilization of the esophagus, characterized in that the esophagus is mobilized in the lower thoracic section before it is cut off from the cardinal section of the stomach, controlling the vital activity of the mobilized section by electromyography and lower the duodenum to the level of the liver.