RU2121304C1 - Jejunogastroplastic method for making gastrectomy operation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making gastrectomy operation. Artificial stomach is created from jejunum intestine graft. Esophagojejunal anastomosis and jejunoduodenal anastomosis are created. Intestine graft length is 16 cm. The esophagojejunal anastomosis is created as end-to-side anastomosis. Two incisions of seromuscular membrane are made on distal part of the graft. The superior incision has elliptic shape. The like incisions are made also on proximal end of duodenum stump. Valve anastomosis is created after applying the graft anastomosis. The intestine part is invaginated. The inferior and superior boundaries of the incision are sutured together. EFFECT: prevented postoperative disorders of gastroenteric tract functioning.

Description

 The invention relates to medicine, surgery, specifically to methods of eunogastroplasty for gastrectomy and subtotal distal gastric resection.

 Known methods of eunogastroplasty are, as a rule, cutting a transplant from the small intestine up to 20-25 cm long and applying endoduodenal and esophageojunoanastomoses, end-to-end and end-to-side, in some cases leave part of the pyloric pulp, “corrugate” the graft, include antiperistaltic inserts - which helps to slow the passage of food through the intestines and normalize the digestion process.

 The disadvantages of the above methods is, as a rule, very low efficiency in terms of preventing dumping syndrome and bile reflux from the duodenum to the graft. In addition, “long” grafts (from 20 cm or more) can lead to the formation of bends and even inversion of the latter.

 Closest to the proposed one is the method proposed by A. M. Ganichkin [Ganichkin AM, Reznik SD Methods of restoring gastrointestinal continuity during gastrectomy. L .: Medicine, 1973], which consists in the following: after performing a gastrectomy, cutting out a small intestinal transplant with a length of 20 - 25 cm, a jeunoduodenoanastamosis is formed in such a way that the end of the graft is introduced into the duodenum, due to which a kind of "bauginium damper" is formed in the anastamosis zone. However, this method does not solve the problem of post-gastroresection disorders - as mentioned above, long grafts are prone to the formation of bends and inversion both in the early and in the distant postoperative period.

 The purpose of the invention is the prevention of post-gastroresection disorders of the gastrointestinal tract (dumping syndrome, gastritis reflux and esophagitis reflux).

 The goal is achieved by a new method of eunogastroplasty in gastrectomy and subtotal distal gastrectomy, consisting of an upper median laparotomy, gastrectomy or subtotal distal gastric resection, the formation of an artificial stomach from a jejunum transplant, and the application of esophageal and juveno-duodenastomoses, which makes up 16, which cm, as well as by exfoliating the muscular membrane from the submucosal esophagus, muscle pulp is formed, after which valve esophageoyeuno is applied end-to-side astamosis, two sections of the serous-muscular membrane are made on the distal part of the graft, the upper one being an ellipse, similar sections are also performed on the proximal end of the duodenal stump; stitching the upper and lower edges of the cut.

 The method is as follows: from the upper median access perform gastrectomy or distal subtotal resection of the stomach. In the abdominal section of the esophagus by exfoliating the muscle membrane from the submucosal base and hemming it in the form of a cuff, leaving an excess of the mucous-submucous membrane to form muscle pulp. A transplant from 14 to 16 cm long is cut out of the jejunum 20 cm below the Trentz ligament. The integrity of the jejunum is restored by anastamosis end to end. The oral end of the graft is sutured tightly. On the anti-mesenteric side of the latter, on a rectangular area of 2x3 cm in size, blunt and sharp peel and remove the serous-muscular membrane (Fig. 1). Form valvular esophagoejunoanastamosis - end to side. The back row of sero-muscular sutures passes through the lower edge of the formed muscle pulp of the esophagus and the upper edge of the sero-muscular membrane of the mucous-submucosal area of the transplant. Then the corners of the mucous-submucosal base of the anastamosed organs are sutured with suture-holders, superimposed with catgut thread 00. One thread of the latter from the left corner imposes a mucous-submucosal suture to the middle of the posterior lip of the anastomosis. Similarly impose and the front mucous-submucosal suture. Next, the anterior sero-muscular nodal sutures passing through the lower edge of the muscular pulp of the esophagus and the lower edge of the serous-muscular membrane of the formed mucous-submucosal area complete the formation of esophagoejunoanastamosis (Fig. 2, 3).

 Then, over the distance of 4 cm, the distal end of the graft is mobilized parietally. Having departed from the free end of 5 mm, the serous-muscular membrane of the transplant is dissected circularly. Above this incision, 2.5 cm to the mesenteric part dissect the serous-muscular membrane in the form of an ellipse, while more capture the anti-mesenteric part of the intestine (Fig. 4). The proximal end of the stump of the duodenum is mobilized for 3 - 3.5 cm from the edge. 0.5 cm above the site of dilution of the pancreatic head, the sero-muscular membrane is circularly dissected. 2 - 2.5 cm above this section similarly perform another section. Impose an invagination-valvular jeunoduodenoanastamosis. The posterior row of nodular serous-muscular sutures is placed between the upper edge of the ellipsoid section of the graft and the lowest edge of the serous-muscular membrane of the duodenal stump (Fig. 5). The corners of the lower edge of the mucosal submucosal membrane of the graft and the upper edge of the mucous submucous membrane of the duodenum are sutured with stitches-holders according to the method described above, two counter catgut ligatures impose the posterior and then the front mucous-submucous sutures. The formation of jeunoduodenoanastamosis is completed by the imposition of anterior nodular serous-muscular sutures on the upper edge of the ellipsoid section of the graft and the lowermost edge of the serous-muscular membrane of the duodenum (Fig. 6). When tying the latter, the distal portion of the graft and the proximal portion of the duodenum are immersed (Fig. 7), which, when invaginated, form a valve (Fig. 8). The operation is completed by conducting a microprobe into the jejunum below the zone of banastamosis and a probe into the transplant for decompression.

 Enteral nutrition through a microprobe up to 5-6 days after surgery is a feature of the early postoperative period.

 According to the proposed method, 28 patients aged 36 to 72 years were operated on. 21 patients had gastric cancer, a giant ulcer in one, four cardiac gastric ulcers, and one patient underwent reconstructive surgery for peptic ulcer anastamosis and dumping syndrome after Billroth-II gastric resection. Gastrectomy performed in 20 patients, distal subtotal seven and one reconstructive resection. Complications in the early postoperative period in our patients were not observed.

 All patients in the early and long-term postoperative period underwent a set of examinations, including laboratory and instrumental methods of research. 28 patients were examined.

 The results of endoscopic examination of patients 2 months after surgery. There were no changes in the esophagus, its mucosa was not changed, the anastomosis is closed, it is freely passable, when inflated with air it opens up to 12-14 mm. The type of transplant mucosa is characteristic of a small intestine of normal color with transverse folds. Compared with the endoscopic picture two weeks after surgery, the folds are more pronounced. Anastamosis with duodenum closes, opens when insufflated with air. The tube of the apparatus passes freely into the duodenum, where, as a rule, bile is present, which is not observed above the zone of juvenoduodenoanastamosis.

 With an X-ray examination after two months. The contrast mass passes freely along the esophagus, the anastamosis peristalsis, opening up to 20 mm. After a gastrectomy, the graft is conical in shape with a gas bubble in the proximal region. The transverse size of the graft expanded to 5-6 cm more in the upper part. Evacuation of contrast in the duodenum occurs after 3-4 minutes. Eunoduodenoanastamosis peristalsis, opening to every 3-4 peristaltic waves of the graft up to 2.5 cm. After an hour and a half in the graft there are traces of contrast mass, most of it in the loops of the jejunum.

 The content of bile acids in the graft was equal to their normal content in a healthy stomach.

 After 2 to 3 months, patients switched to a common table and 3 to 4 meals a day.

 Clinical example 1. Patient D., 34 years old, was treated in 1 x / o from 14.02 to 02.25.94, with a diagnosis of malignant gastric ulcer. From the anamnesis: sick from 12/04/93, before pain was not bothered. When FEGDS detected gastric ulcer up to 3 cm in diameter.

 On the background of conservative therapy, the ulcer decreased, but with repeated biopsy, cells of the cricoid-shaped cancer were found. Received for surgical treatment. On admission: satisfactory condition, pathology from the internal organs not found, peripheral l / y not increased, distant metastases were not found.

 After preoperative preparation, the patient was operated on. 02.16.94, operation: a total distal gastric resection, primary eunogastroplasty, expanded lymphadenectomy, drainage of the abdominal cavity.

 The postoperative period is smooth, healing by primary intention, feeding through the probe up to 6 days. On the ninth day after the operation, in satisfactory condition, was discharged for outpatient treatment. 6 months after surgery: satisfactory condition, no complaints. FEGDS: the esophagus is not changed, the cardia is closed, in the cult of the stomach a moderate amount of semi-digested food. Anastamosis with jejunum end to end - we pass freely, the length of the graft is about 15 cm, its appearance is characteristic of the jejunum. Anastamosis with duodenum is closed, freely passable, the mucosa in the anastamosis zone is not changed.

 Clinical example 2. Patient S., 54 years old, was treated in 1 x / o from 18.10 to 10.30.93, with a diagnosis of malignant gastric ulcer. From the anamnesis: sick for about a year, before pain was not bothered. When FEGDS detected gastric ulcer up to 2.5 cm in diameter.

 Biopsy revealed low-grade cancer cells. Received for surgical treatment.

 On admission: satisfactory condition, pathology from the internal organs not found, peripheral l / y not increased, distant metastases were not found. The abdomen is calm, pathological formations are not determined.

 After preoperative preparation, the patient was operated on. 10/20/93 operation: gastrectomy, primary eunogastroplasty, expanded lymphadenectomy, drainage of the subhepatic space.

 The postoperative period is smooth, healing by primary intention, feeding through the probe up to 6 days. On the tenth day after the operation, in satisfactory condition, was discharged for outpatient treatment. FEGDS: the esophagus is not changed, the anastamosis with the jejunum is closed, swollen with air up to 1.5 cm, we pass freely, the length of the graft is about 15 cm, its appearance is characteristic of the jejunum. Anastamosis with duodenum is closed, freely passable for 11 mm apparatus. The mucosa in the anastamosis zone is not changed.

 Cross-probe duodenography from 10.24.93: a contrast agent was introduced through a microprobe into the transplant, the latter is fed portionwise into the duodenum, anastomosis opening up to 15 mm. There is no contrast casting into the transplant from the duodenum.

 Thus, the proposed method eunogastroplasty can prevent the development of a number of postoperative complications associated with impaired passage of food through the gastrointestinal tract. An invagination-valvular anastamosis in the area of the uniuodenal anastomosis helps to restore the motor-evacuation function of the "stomach", prevents duodeno-gastric reflux and the development of dumping syndrome.

Claims (1)

 The method of jejunastroplasty for gastrectomy, which consists in the upper median laparotomy, gastrectomy, the formation of an artificial stomach from a jejunum transplant, the imposition of pulp-valvular esophagoejuno-and jeunoduodenostomy, characterized in that the length of the transplant is 16 cm, and the pulmonary-endoscopic valve , on the distal part of the graft two sections of the serous-muscular membrane are made, the upper one being in the form of an ellipse, similar sections are also performed at the proximal end e stump of the duodenum, after anastomosis of the graft and duodenum form a valve anastomosis by invagination of this site and stitching of the upper and lower edges of the incision.

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