RU2134550C1 - Method of gastrostomy - Google Patents

Abstract

FIELD: medicine, particularly, surgery; applicable in operations on esophagus and stomach including plastic operations. SUBSTANCE: method includes removal of seromuscular layer by circumference on rib of body of greater curvature; extension of submucous layer in shape of cone; dissection of mucous-submucous layer; application of two semipurse-string sutures; installation of tube into hole; tying of strings of semipurse-string suture on tube; application of purse-string suture to submucous layer adjacent to seromuscular layer; burying of tube into stomach lumen; tying of suture; application of purse-string suture to seromuscular layer with some departure from defect. Tube is buried and suture is tied. EFFECT: higher efficiency of method due to unimpeded possibility of performance of plastic operations on esophagus and cardi, and fast closing of fistula after removal of tube. 5 dwg

Description

 Gastrostomy is the most common of palliative surgeries used for obstruction of the esophagus, both in our country and abroad. Depending on the pathological process (tumor, cicatricial narrowing, achalasia of the cardia, etc.), this operation is performed for various purposes: to nourish patients, retrograde esophageal bougienage, during plastic surgery on the esophagus, the use of radiation and combination therapy for an inoperable esophagus, with ulcerative inflammatory processes and bleeding, as a stage in the preparation of weakened, depleted patients for plastic surgery on the esophagus and cardia.

 There are more than 100 modifications of the gastrostomy, which indicates the absence of a generally accepted method, devoid of flaws and the desire of surgeons to improve the technique of surgery.

 G.S.Topover (monograph "Gastrostomy", 1940) divided the existing methods of gastrostomy into 5 main groups.

 Group 1 - gastrostomy methods in which the front wall of the stomach is pulled into the wound in the form of a cone and sutured to the abdominal wall. At the same time, the channel of the gastric fistula is lined along the entire length with the mucous membrane (V.A. Basov, 1842; Blondlot, 1843; Hacker, 1886; Girard, 1888; I.F.Sabaneev, 1890; I.T. Shevchenko, 1950; V. M. Voskresensky, 1939; Ulmann, 1894).

 Group 2 - gastrostomy methods in which a channel is formed from the anterior wall of the stomach. In this case, the fistula canal is lined with a serous membrane and granulation tissue (P.I. Dyakonov, 1903; K.P. Sapozhkov, 1945; Witzel, 1891; Kocher, 1902; Mardvedel, 1896; Stamm, 1894; Senn, 1896; Kader, 1896 )

 Group 3 - gastrostomy methods in which the fistula canal is formed from an isolated section of the intestine, sewn between the stomach and the skin of the abdomen (Tavel, 1906; Roux, 1907; Kelling, 1911; Wulliet, 1911).

 Group 4 - gastrostomy methods, in which they cut stalked flaps from the stomach wall and form a tubular fistula from them (M.M. Trofimov, 1898; Ya. O. Halperin, 1913; Deradze, 1901; Spivack, 1929; Lowry, Sorenson, 1932 and etc.).

 Group 5 - gastrostomy methods in which the canal of the gastric fistula is lined with skin epithelium, which surrounds a rubber catheter sewn into the stomach wall according to the Witzel method (Warath, 1911; Steward, 1918; Stahnke, 1928).

 Many of the existing metastases of gastrostomy are of historical interest only. The initial methods of gastrostomy by simply stitching the anterior wall of the stomach to the abdominal wall without the formation of pulp (Sedillot, 1849; Fenger, 1854, etc.) are not currently used due to the constant leakage of gastric contents through the fistula and painful irritation of the skin of the abdominal wall.

 Due to the complexity of the surgical technique and the often observed complications, most surgeons also left such gastrostomy methods in which the fistula channel is formed from an isolated segment of the small or large intestine (Tavell, 1906; Kelling, 1911), or the gastric cone is pulled through oblique canals in the abdominal the wall (I.F.Sabaneev, 1890; Frank, 1893), as well as through the costal cartilage (Hahn, 1890).

 Gastrostomy methods have also not met expectations, in which the channel of the gastric fistula is lined with a skin graft taken from the hip or abdominal wall (Warath, 1911; Steward, 1918; Stahnke, 1928), since the separation of skin epithelium by gastric contents quickly leads to a violation of the sealant of the fistula and falling out of the tube.

 In 1891, Witzel's Trendelenburg textbook described a new method of gastrostomy, developed by him on corpses and used in 2 patients suffering from obstruction of the esophagus. Witzel’s method, in the original presentation of the author, consists in creating a channel that goes obliquely from top to bottom and from left to right, stitching the free edges of two parallel folds on the front surface of the stomach to the small hole in the pyloric section of the stomach.

 The main disadvantage of the Witzel method is the need to wear a rubber tube, which often falls out of the fistula, followed by constant leakage of gastric contents to the outside, which leads to maceration of the skin and significantly aggravates the condition of patients. Re-introducing the tube into the stomach is difficult and the fistula may close on its own. With a long-term existence of the fistula, the channel from an oblique turns into a direct one, which also leads to the loss of the tube and a violation of the tightness (B.E. Linberg, Bier). The introduction of a rubber tube into the lower part of the stomach does not allow the patient to take the right amount of food, especially with a sharply shriveled stomach. Therefore, the method of gastrostomy in the form as proposed by Witzel, is currently not applied.

 Gernez and Ho - Dac-Di (1930) suggested introducing a tube into the stomach through the internal opening of the canal located in the cardial part of the stomach, and not in the pyloric. Under these conditions, the hole in the cardiac part of the stomach is not in contact with the liquid contents, but is located at the level of the gas bubble ("air hole" according to the terminology of the authors). This is, in their opinion, the main reason for the retention of gastric contents. The second reason they consider the presence of an oblique parietal canal formed from the anterior wall of the stomach and going from top to bottom and from left to right.

 There are many modifications of the Witzel method, the purpose of which is to improve the tightness of the fistula (P.I. Dyakonov, 1903; V.A. Oppel, 1907; M.M. Ginzburg, 1930; D.E. Shklovsky, 1938; S.D. Ternovsky , 1963). L.M. Niskevich (1938), evaluating the Witzel technique and its modifications, observed tube prolapse in 42.3% of cases, gastric contents flowing past the tube in 35.2%, maceration of the skin of the abdominal wall around the tube, and in 7.7% of cases divergence of the edges of the wound. When falling out of the fistula in 3.5% of patients, its reverse administration into the stomach was impossible, and in 4.2% a repeated gastrostomy was performed. Many authors point to the difficulty of reintroducing a tube that has fallen out of the fistula and the possibility of it getting into the free abdominal cavity with the subsequent development of peritonitis and death (S.P. Fedorov, 1903; A.M. Zabludovsky, 1938; B.A. Petrov, 1938 ; V.R. Zinevich, 1957; V.E. Mlynchik, 1960 and others).

 G.S.Topover (1934) proposed a new gastrostomy technique. The front wall of the stomach, closer to the cardia, is pulled in the form of a cone. Next, 3 subsecond purse string sutures are applied at a distance of 1.5 - 2 cm from each other. Open the lumen of the stomach at the apex of the cone. Through the hole made, a rubber tube with a diameter of up to 1 cm is introduced into the stomach. Pouches around the tube are alternately tightened, starting from the first. Thus, a corrugated cylinder is obtained from the anterior wall of the stomach, standing up to 4 cm. The formed cylinder is fixed to the parietal peritoneum and skin. Gastrostomy fistula with this method is lined throughout the gastric mucosa. In the course of the fistula, there are 3 valves formed by purse string sutures from the folds of the mucous membrane and causing, according to the author, hermeticity.

 V. A. Vorobyov (1940), based on observation of patients operated on according to the method of G. S. Topvere, notes the following complications; erosion of the skin around the fistula (46%); violation of the integrity of the fistula due to the eruption of purse string sutures in the lumen of the stomach; phlegmon of the abdominal wall and peritonitis; necrosis of the gastric cone with excessive tightening of purse string sutures. Similar complications were observed by I.D.Sadykov (1958), M.P. Suetin (1938), E.G. Lokshina (1952). B.A. Petrov (1938) described the case when silk ligatures stood out from the fistula one after another with a violation of the tightness of the fistula. Of the 26 patients operated on by him, 6 died. According to M.P. Suetina (1938), mortality is 46.7%, hermetic seal failure in the immediate and long-term postoperative period was 75%, which was associated with the eruption of purse string sutures into the cone lumen. In addition, to apply fistula according to Toprover, a free area on the front wall of the stomach with a diameter of 8-10 cm is required. Therefore, with small sizes of the stomach, which are mainly observed in this category of patients, this method is also not applicable. This operation leads to a violation of the blood supply in the gastric cone due to the pulling of it with three-story purse string sutures, which, in some cases, causes atrophy of the mucous membrane and muscle layer of the gastric cone with loss of valve properties, in others - the onset of mucosal necrosis, eruption of purse string suture threads with violation hermetic fistula. And, finally, a gastrostomy according to Toprover and its modifications (M.A. Blagoveshchensky, 1950; Glansman, 1939) lead to gross deformation of the anterior wall of the stomach with a violation of all the functions of the organ.

 Stamm (1894) in an experiment on dogs developed a gastrostomy method with the formation of a direct channel. The abdominal wall incision is transrectal on the left. A cone is formed from the front wall of the stomach, at the base of which a purse string suture is applied. Through an incision in the apex of the cone, a rubber catheter is inserted into the stomach, which is fixed with a suture to the wall of the stomach. Further, the catheter is invaginated into the purse string suture along with the gastric wall. The purse string suture is tightened onto the catheter. The stomach is sutured to the peritoneum and, in addition, additionally fixed by suturing the ends of the purse string suture through the entire thickness of the abdominal wall. The wound of the abdominal wall is sutured to the tube. The method of the Strain in humans was first applied by Senn (1896). Most surgeons use a modification of this operation, called the Strain - Senn - Kader gastrostomy, in which the tube is immersed in the stomach with two purse string sutures. The advantage of the method is its simplicity, speed of execution and accessibility for a wide range of surgeons.

The negative sides of the method are: the constant wearing of the tube in the fistula, the possibility of its prolapse and leakage of gastric contents, impaired blood supply and innervation of the stomach wall at the stoma site, the inability to visually monitor the completeness of hemostasis of the vascular mucosa and submucosal layers located inward from purse string sutures, and, as a result of this, a high probability of bleeding in the early and long-term postoperative period. Due to the fact that the channel of the fistula is made by the serous membrane of the stomach, a slow, and in a number of cases complete absence of spontaneous closure of the stoma occurs
Goal. Reducing the recovery period of patients, preserving all the functions of the stomach, providing the possibility of plastic surgery on the esophagus and cardia.

 Tasks. 1). To develop an organ-preserving method of gastrostomy.

 2). Maximize blood circulation and tissue innervation in the gastrostomy area.

 3). Do not violate the secretory, motor-evacuation and reservoir functions of the stomach.

 4). To develop a gastrostomy method that can be used in patients with esophageal disease for preoperative preparation and in the postoperative period.

 5). To develop a method of gastrostomy that does not interfere with plastic surgery on the esophagus and cardia.

 6). Ensure rapid closure of the fistula after removal of the tube by creating an areflux mechanism during stoma formation.

 The essence of the invention is as follows: on the edge of the body of a large curvature of the stomach, the serous-muscular layer is removed and then in the resulting defect with purse-string sutures, a gastrostomy is formed inside the submucous case.

 The method is as follows. Provide access by upper midline laparotomy. One or two transverse vessels going to the greater curvature of the stomach, parietally intersect between the clamps and bandage (Fig. 1). Through the front and back walls of the stomach, departing from the rib of great curvature, 2 serous-muscular arms are sewn (1,2), with the help of which the mobilized section is pulled into the wound. Between the holders, the serous-muscular layer in the form of a circle with a diameter of 2-2.5 cm to the submucosa (3) is removed and the latter is maximally stretched in the form of a cone. Dissect the mucous-submucosal layer. Over the edge of his twisting continuous sutures, turning the mucous membrane, impose 2 half-kit (4,5) with an absorbable thread atraumatic needle (Fig. 2). A tube (10) is inserted into the hole, on which two adjacent threads (6.7) are tied from different half-mesh seams (Fig. 3). For the submucosal layer directly adjacent to the serous-muscular muscle, a second purse string suture (8) is applied with a monolithic thread with an atraumatic needle. By immersing the gastrostomy tube (10) in the lumen of the stomach, the suture is tied, the threads are taken on the holder. The third, serous-muscular purse-string suture (9), is applied with a monolithic thread, departing from the defect in the serous-muscular layer (3). Cut the threads from the previous purse string suture. Immersing the tube in the stomach, tie the stitched seam and take it to the holder. Thus, the gastrostomy tube is located almost in its entirety in the submucosal case (11) (Fig. 4). The tube (12) along with the threads from the third purse string suture is held by Mikulich's clip through a puncture of the anterior abdominal wall at the intersection of the left midclavicular and mesogastric lines and fixed with the same threads to the skin (Fig. 5). The wall of the stomach around the fistula is hemmed to the parietal peritoneum with interrupted serous-muscular sutures. The abdominal cavity is sutured in layers tightly.

 The method was tested on 105 patients in the clinical setting of the Republican Center for Functional Surgical Gastroenterology (RCCH).

 Patient R., 17 years old N disease 95.

 Diagnosis: achalasia of the cardia of the 3rd degree.

 He entered the clinic 01/22/96. Complaints about the difficulty of passing food into the stomach, a feeling of fullness behind the sternum, weight loss of 10 kg over the past year, general weakness, belching and vomiting of recently eaten food.

 Anamnes morbi. He was ill for about 4 years, when he first felt difficulty swallowing. In October 1995, he was treated in the gastroenterological department. The diagnosis of achalasia of the cardia of the 3rd art. Surgical treatment recommended.

 Anamnes vitae. Tuberculosis, Botkin’s disease, veins, denies the disease. An allergic history is not burdened.

 Objectively. The patient has a proper physique, moderate nutrition, and his condition is satisfactory. The skin is clean, peripheral lymph nodes are not enlarged, painless. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear, rhythmic. Pulse 80 beats per minute, A / D 120/80 mm RT. Art. The tongue is moist, the stomach is soft, painless in all departments. The liver and spleen are not enlarged. Shchetkin's symptom is negative. Physiological administration is normal.

Laboratory research data. General blood analysis:
erythrocytes - 5.3 T / l; Hb -176.1 g / l; CPU 1.0;
white blood cells - 5.9 G / l; B-1%; E-2%; P-8%; C-65%; L-20%; M-4%. Ht-0.53, ESR-20 mm / h
Urinalysis: color-s / f, specific gravity-1021, pH-5.0, protein - 0.25 g / l, glucose-abs, red blood cells-abs, white blood cells-0-1-2 p / e.

 Biochemistry: glucose-5.5 mmol / l, bilirubin-16.7 mmol / l, urinary-5.3 mmol / l, creatinine-87.7 mmol / l, medium molecules-205 cu, Alt-0.07 mmol / h • l, Ast - 0.35 mmol / h • l, amylase-12.0 g / l • h, total protein-85 g / l. HBsAg-not detected, MOP-neg., Blood group-2 (A) Rh-pos.

 Instrumental research data. FGDS. The esophagus is freely passable, in the lumen there is a large amount of mucous fluid mixed with food masses. The mucous membrane of the visible sections of the esophagus is pink. The lower third of the esophagus has been expanded to 3 cm. The cardinal pulp is closed, spasmodic, and the apparatus with a diameter of 1.0 cm was difficult to get through. The stomach is of normal shape and size. The gatekeeper is round, functioning, we are passing. The duodenal bulb of the correct form, pink mucosa, postbulbar departments without features. Conclusion: achalasia of the cardia of the 3rd degree, superficial gastritis.

 X-ray of the esophagus, stomach and duodenum. The esophagus is expanded to 5 cm, contains food masses. In the lower third of the retrocardial segment, it begins to conically taper to 0.6 cm in the subphrenic segment. The contours are clear, even. The esophagus is emptied after 30 minutes.

 Conclusion: achalasia of the cardia of the 3rd degree. 01/31/96, operation: extirpation of the mucous-submucosal layer of the esophagus with simultaneous plastic surgery of the colon, gastrostomy, drainage of the abdominal cavity.

 Under endotracheal anesthesia with mechanical ventilation, an upper-mid-lower laporotomy was performed, as well as access correction RSK-10. The abdominal esophagus has been mobilized. The esophageal-gastric transition is narrowed. Above it, the esophagus expanded to 5 cm. Mobilization of the left half of the colon was completed, a large intestine transplant was cut. An end-to-end transverse-sigmoid anastomosis is imposed. A left-side collotomy of the inside and parallel to the sternocleidomast 10 cm long was performed. The esophagus was isolated, the muscularis was transversely opened, the submucous layer was released and crossed. In the abdominal cavity, the esophagus is cut off from the stomach and the submucosal layer is also isolated. A probe was inserted through the oral end of the crossed esophagus in the direction of the abdominal, to which the mucous-submucous layer is attached. The latter is extirpated when the probe is removed. A transplant was performed inside the remaining adventitio-muscular case. Formed: areflux gastrointestinal anastomosis at the site of the esophageal-gastric transition and esophageal-colonic anastomosis on the neck. Two transverse vessels going to the greater curvature of the body of the stomach, parietally crossed between the clamps and bandaged. On the edge of the mobilized section of great curvature, the serous-muscular layer in the form of a circle with a diameter of 2.5 cm to the submucosa is removed and the latter is maximally elongated in the form of a cone. Dissected mucous-submucosal layer. Over the edge with its continuous twisted seams, turning the mucous membrane, 2 half-kits were put on by an absorbable thread with an atraumatic needle. A gastrostomy tube is inserted into the hole, on which 2 adjacent threads are tied from different half-mesh seams. In the submucosal layer, bordering on the serous-muscular, a second purse string suture was applied with a monolithic thread with an atraumatic needle. Plunging the tube into the stomach, the suture is tied. Having departed from the defect in the serous-muscular layer, a third purse string suture was applied. The latter is tied up and taken to the holder. The gastrostomy tube along with the threads from the third purse string suture is held by Mikulich's clip through a puncture of the anterior abdominal at the intersection of the left midclavicular and mesogastric lines and is fixed with the same threads to the skin. The wall of the stomach around the formed stoma is hemmed to the parietal peritoneum by interrupted serous-muscular sutures. Drainages are installed in the right and left side flanks of the abdomen. The abdominal cavity is sutured in layers tightly.

 The postoperative period was uneventful. Primary healing. Discharged in satisfactory condition on the 14th day after the operation. Within 1 month, the patient was fed through a gastrostomy.

 03/18/96, during the control examination, the gastrostomy tube was removed, the stoma was closed on the 3rd day. Leakage of gastric contents was not observed. The patient's condition is satisfactory, there is no dysphagia syndrome.

 This method of gastrotomy allows you to: reduce the recovery time of patients by 20%, to ensure closure of the stoma for 2-3 days after removal of the gastrostomy tube; save in full all the functions of the stomach; much faster to prepare patients for plastic surgery on the esophagus and cardia and does not interfere with their conduct; accelerate the rehabilitation of patients in the postoperative period.

Claims (1)

 A method of gastrostomy, including immersion of the gastrostomy tube in the lumen of the stomach with purse-string sutures, characterized in that a serous-muscular layer in the form of a circle is removed on the edge of a body of large curvature, a submucous layer is drawn in the form of a cone, a mucous-submucous layer is dissected, two half-kisets are applied to its edge , a tube is inserted into the hole and the threads from half-burs are knotted on the tube, then a purse string suture is placed on the submucosa adjacent to the serous-muscular muscle, the tube is immersed in the lumen of the stomach and the suture is tied, After which, on the serous-muscular layer, stepping back from the defect, a purse string suture is applied and knotted on the tube when it is immersed.

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