RU2146499C1 - Method for creating esophagoenterostomy after performing gastrectomy in case of stomach carcinoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting muscular layer of the esophagus to submucous layer. Temporary row of sutures is created through all intestine wall layers. The needle is introduced near the mucosa base. The suture is conducted through all intestine wall layers, mucous and submucous esophagus wall layers. In making the finished row of sutures, the back wall is sutured with a single U-shaped suture. The anterior wall of the finished row of sutures is formed by means of semi-purse-string sutures. Threads are taken as one thread from every lateral holders, for being used in doing it. When putting-in stitches over the anterior finished row of sutures, two sledge sutures are applied. Purse-string suture is put over the mesenteric edges of intestine loops with mesenterium. EFFECT: prevented suture inconsistency.

Description

 The present invention relates to medicine, namely to surgical oncology.

 In gastric cancer surgery, at present, gastrectomy is becoming the most common operation. In addition to fulfilling all the conditions ensuring the radical nature of the operation, the surgeon faces another important task: restoring the continuity of the gastrointestinal tract. Moreover, the esophageal-enteric anastomosis should be reliable, simple and physiological. The peculiarities of its healing are associated with the absence of serous cover, friability of the muscle layer of the esophagus, impaired blood supply due to ligation of the left gastric artery (the upper branch goes to the esophagus), rich in microflora of comparable hollow organs. Negative factors also include: a large invasiveness of the intervention, a violation of the metabolic processes of nutritional and tumor genesis, old age and concomitant pathology. According to the data of Yu.I. Putyutko and co-authors, for 6 years of activity of the abdominal surgical department of the All-Russian Scientific Center for Surgery, anastomosis failure after gastrectomy occurred in 8.8% and led to death in 87.2%, which amounted to 32.3%.

 More than 100 years have passed since the first successful gastrectomy, which Schlatter performed in 1897. And it is quite natural that during this time many methods were proposed for the formation of the esophageal-small intestinal anastomosis. One of the most common esophageal-intestinal anastomoses containing elements of plastic cover for sutures is the anastomosis proposed by the Polish surgeon Gilyarovich (Chir, 1931, 58, 2613-2617, "The technices of total gastroectomy"). This anastomosis has two significant positive qualities: the formation of a wide serous channel for the esophagus stump and the creation in the anastomosis of a valve mechanism that prevents reflux of intestinal contents into the esophagus. A significant drawback of the Gilyarovich anastomosis is the tension in the joints of the anterior wall and the difficulty in covering it with a loop of the intestine. Taking this into account, G.V. Bondar and co-authors proposed to preliminarily create a serous canal for the esophagus on the prosthesis of the appropriate diameter (G.V. Bondar, Yu.D. Clinical Surgery ", 1971, N5, p. 1-5.). Despite the proposed improvements, the comparison of stitched organs at an extremely sharp angle, the fixation of the posterior wall of the esophagus over a large length to the intestinal wall, as it creates a spur in the region of the posterior lip of the anastomosis, which prevents the free approach of the front lip. The front wall of the intestine loses mobility, which leads to tissue tension and frequent eruption of the muscle layer of the esophagus (Yu. S. Gilevich, V.I. Onopriev. Anastomoses in abdominal surgery. 1978, p. 112-113).

 The prototype of the proposed esophagoenteroanastomosis is the technique proposed by Perrotin J. (Technique de l'oesophagoectomie transpleurale gauche. J. Chir., 1950, 66, 273-289). After applying the first row of serous-muscular sutures at a distance of 2-2.5 cm from them, the muscular membrane of the esophagus is circularly incised to the submucosal layer. A muscle cushion forms, which is sutured to the serous membrane of the intestine. They open the intestine, cut off the esophagus 3-4 mm below the muscle cushion and suture through all layers of the intestinal wall and the mucous membrane of the esophagus. Double-row seams are placed on the front wall.

 The disadvantages of the prototype we include: difficulties with invagination of the esophagus into the intestine with interrupted sutures; tension of the anastomosis anterior wall, on the second row of sutures; the absence of plastic elements for sheltering the anastomosis anterior wall with the adductal gut, which leads to a decrease in the possibilities of using the plastic properties of the peritoneum.

Purpose of work:
1) to maintain the positive qualities of the prototype, consisting in the separation of the esophagus to the submucosal layer, which allows the use of the formed muscle cushion and eliminates tissue tension due to the greater elasticity of the mucosa and submucosal layer;
2) to develop the technique of the suture of the "clean" row, allowing the esophagus to be invaginated into the intestine without tensioning the tissues, i.e. with minimal trauma to the muscle layer of the esophagus;
3) create a serous canal compensating for the difficulty of healing the anterior wall due to the comparison of dissimilar tissues;
4) to form a valve mechanism that eliminates the reflux of intestinal contents into the esophagus and the syndrome of the afferent loop;
5) to exclude the possibility of the spread of intestinal contents, in case of insolvency, below the mesentery of the transverse colon.

Objectives of the invention:
1) given the severity of the general condition of cancer patients, often elderly age, the abundance of concomitant pathology, and, despite all this, the need for expanded lymphadenectomy to minimize surgical trauma due to the ease of performing reliable esophagoenteroanastomosis;
2) making the most of the positive aspects of the prototype, eliminate its weak aspects regarding the rather high probability of insolvency in the anterior wall of the anastomosis, afferent loop syndrome, reflux esophagitis;
3) to achieve optimal functional results in the long-term postoperative period by imparting valvular functions to the adducting gut;
4) test the proposed methodology and prove its practicality in a large flow of patients.

 The essence of the invention lies in the fact that the technique of “clean” row sutures has been changed: the back wall is hemmed with one U-shaped suture, the front wall with half-sutures, using one thread from the side holders, and two suture sutures, pulling and screwing the intestinal wall to the front wall of the esophagus . The jejunum adduction loop is used to cover the esophagus adventitia with the serous membrane and at the same time create a valve mechanism that excludes the reflux of intestinal contents into the esophagus due to its circular gut coverage. A purse string suture is applied to the mesenteric edges of the loops of the intestine with the mesentery, immediately below the anastomosis, to eliminate the channel connecting the anastomosis zone with the abdominal cavity below the mesentery of the transverse colon.

 Esophagoenteroanastomosis has been tested in the gastroenterological department of the Krasnodar Regional Clinical Oncology Center since 1990, for more than 400 patients.

 The proposed method is as follows. An upper middle laparotomy is made that borders the navel on the left. To improve surgical access, wound expanders M.Z.Sigala, A.I. Lisitsina (1971) are used. After an audit of the abdominal organs, the stomach is mobilized with all the ligaments and epiploons. The duodenum is flashed with the UO-60 device, two half-sets and a U-shaped suture. Before cutting off the esophagus, its muscle layer is incised to the submucosa. Then, departing 0.5 cm from the edge of contracted muscles, a L-shaped clamp is applied, along the edge of which the esophagus is cut off. After changing gloves and tools, in the avascular site of the mesentery of the transverse colon, spend the initial loop of the jejunum. At a distance of 30-35 cm from the tracheal ligament, provisional sutures are applied to the mesenteric edge of the jejunum: U-shaped and two lateral. The distance between the sutures is chosen depending on the width of the esophagus. Further, pre-applied sutures are sutured to the esophagus 2.0-2.5 cm above the contracted muscle roller with the mandatory capture of the submucosal layer. First, the posterior U-shaped is stitched, the threads of which are cut off, then the threads that are lateral along the edge of the esophagus are taken onto the holders. Three distal sutures are similarly applied at the level of the muscular esophagus formed. An electric knife opens the front wall of the intestine in the transverse direction, departing 1.0 cm from the distal "clean" sutures. Bleeding vessels are thoroughly coagulated. A "dirty" row of sutures is formed with the capture of all layers of the intestinal wall, submucosal layer and esophageal mucosa, with nodules in the lumen of the organs. The front “clean” row of sutures is formed due to the distal lateral filaments, with which two half-kits are placed on the front wall of the intestine, and then with two “sled” sutures, the transverse shoulder of which is carried out somewhat obliquely in the muscular wall of the esophagus, with the obligatory grip of the submucosa. Thus, the anastomosis is invaginated into the intestine. The proximal lateral holders, with the help of half-burs, additionally invaginate the esophagus. With the right proximal retainer, - with one end they catch the diaphragmatic peritoneum - with the other pull up to approach the outlet - the leading loop of the intestine. The esophagus is enclosed in a serous ring, which is closed at the top by suturing the wrapped leading loop to the diaphragmatic peritoneum. The next impose a serous-muscular-serous suture between the mesenteric edges of the adducting and abducting loops of the intestine and its mesentery. This suture is placed 3.0-3.5 cm below the anastomosis, they close the channel of the infection below the mesentery of the transverse colon, localizing the inflammatory process in case of failure of the anastomosis. Finally, the esophagus is covered with two serous-muscular sutures that connect the anti-mesenteric edges of the adducting and diverting intestinal loops. Further, enteroenteroanastomosis is formed at the level of the mesentery of the transverse colon. The operation is completed by staging silicone vacuum drainage under the lower edge of the left lobe of the liver closer to the anastomosis. Drainage is removed on the 5-6th day after radiological monitoring of the viability of the anastomosis, trial drinking and the cessation of lymphorrhea with extended lymphadenectomy.

 Examples.

Patient Bondarenko V.A. 60 years old entered the gastroenterological department of the Krasnodar Regional Oncology Center on October 12, 1994 with a diagnosis of gastric cancer of the body T3N1MO IIIA stage, 2 clinical group. Sick for about 6 months, complaints of pain in the epigastrium after eating, a rise in body temperature in the evenings to 37.5 ^o , weakness. I lost 7 kg in the last 3 months. X-ray examination: the esophagus and cardia are freely passable, the body of the stomach is circularly narrowed, there is no peristalsis, the pylorus is passable, the duodenal bulb is not changed, the stomach is mobile. Conclusion: an infiltrative form of cancer of the body of the stomach.

 After preoperative preparation: glucose solution 10% - 400 ml, KCl solution - 2.25 g, insulin - 12 units. iv drip N 5; rr vit. B1, B6 - 1.0 v / m; 10/19/94. under endotracheal anesthesia an operation was performed - laparotomy, extended gastrectomy (R2). During the audit: infiltrative cancer of the stomach, lymph nodes in the left gastric artery are enlarged. An urgent cytological examination of the smear imprint from the enlarged lymph node revealed tumor cells. The stomach is mobilized with all ligaments and epiploons, lymphadenectomy in the volume of R2, with splenectomy.

 Esophagoenteroanastomosis was formed according to the described method. The muscular membrane of the esophagus was dissected after the intersection of both phrenic nerves. The esophagus was cut off 1.5 cm above the cardiac pulp. The length of the abdominal segment of the esophagus turned out to be 3.5 cm. After changing the instruments, gloves and treatment with the chlorhexidine solution of the surgical field, the initial sections of the jejunum were mobilized from adhesions and carried into the upper abdominal cavity through the mesentery window of the transverse colon, formed in its avascular section . 35 cm from the Treits ligament in the mesenteric margin of the intestine, provisional serous-muscular sutures were placed: two on the sides and one U-shaped in the center, the other shoulder then stitching the muscular and submucosal layers of the back wall of the esophagus with the capture of 2.0 cm diaphragmatic peritoneum elements above the formed muscle cushion of the esophagus. The threads were cut. Two other threads sutured the muscular and submucosal layers of the esophagus on the sides. Threads took on the "holders". In a similar manner, distal sutures were formed on the posterior wall of the esophagus with capture of the muscular bead and submucosal layer, while also retaining the lateral filaments. An electric knife transversely opened the front wall of the jejunum for 2.5 cm, made hemostasis and cut off the excess mucosa. They removed the L-shaped clamp from the esophagus and formed a “dirty” row of sutures with nodules into the lumen of the organs after 0.4 cm, with capture at the base of the intestinal mucosa, submucous, muscle and serous membranes, as well as the submucosal and mucous membranes of the esophagus. After processing the surgical field and changing the instrumentation, half-kit was placed on the front wall of the intestine using distal lateral sutures. The serous-muscular membrane was taken into the suture for 1.5 cm; when tying the threads, the intestinal wall shifted upward, drawing closer to the muscular roller of the esophagus. Two “sled” seams according to Yu.E. Berezov were placed at an equal distance from each other, moreover, the transverse shoulder was carried out somewhat obliquely in the muscular shaft of the esophagus. When tying the threads, they combined the front wall of the intestine with the esophagus, invaginating the “dirty” row of sutures. Using proximal lateral holders, with the help of half-burs, grabbing the wall near the mesenteric edge of the intestine with serous-muscular sutures for 1.5 cm, tying it pulled it higher without tension. The left one was cut off, and the right one captured the elements of the diaphragmatic peritoneum and, after preliminary estimation, by turning the leading loop of the intestine from left to right, the latter was fixed with a serous-muscular suture. Thereby, the wall of the esophagus, which was left without a peritoneum, was closed, squeezing it with the circular-leading intestine, which was then additionally fixed to the diaphragmatic peritoneum. Loops of the intestine were deployed and the mesenteric edges of the intestine were sewn 3.5 cm below the anastomosis, capturing the mesentery in several places. Three serous-muscular sutures sutured the anti-mesenteric edges of the abducting and adducting intestines. At the window level of the mesentery of the transverse colon, dissecting it transversely for 2.0 cm, a double-row enteroenteroanastomosis was formed. The mesentery in the area of the transverse colon window was fixed in three places to the intestine. For anastomoses used kapron thread. A silicone drainage was placed in the right hypochondrium through contraception, which was carried out under the hepatoduodenal ligament to esophagoenteroanastomosis. The second drainage is placed in the right hypochondrium in the bed of the spleen.

 The postoperative period was uneventful. The patient received infusion therapy in the amount of 2.4 liters per day, blood transfusion, ampicillin 0.5 g 4 times a day iv, gentamicin 0.08 2 times a day in drainage, p. Vitamin B, sulfocamphocaine 10% -2.0 v / m, solution heparin 5000 units p / abdominal skin 2 times a day. Postoperative course without complications. On the 5th day, an anastomosis fluoroscopy was performed, it functions normally: there is no barium suspension in the adduction loop and esophagus. The patient is under observation to the present. During the control esophago-enteroscopy: the anastomosis is elastic, 3.5 cm in diameter, slightly hyperemic, the discharge loop of the intestine without features.

 Patient LN Serikova, 58 years old, was admitted to the Krasnodar Regional Clinical Oncology Center on March 11, 1997 with complaints of severity in the epigastrium after eating, vomiting in the evenings, weakness, weight loss. On endoscopy: in the stomach, food debris, along the lesser curvature, infiltration with ulceration in the center of 2.0 by 3.0 cm of irregular shape, tissue fragmentation during biopsy. X-ray examination: the esophagus and cardia are freely passable, the stomach on an empty stomach contains fluid, the antrum is circularly narrowed, where the barium depot with the shaft around is also determined, the lesser curvature is infiltrated including the body of the stomach, the pylorus is passed, the duodenal bulb is not changed, gastric displacement is limited. Ultrasound of the liver and pancreas: data for metastatic lesions were not received. Diagnosis: infiltrative and ulcerative cancer of the antrum of the stomach with a transition to the body T3NxMO stage 2, clinical group 2. After preoperative preparation, which consisted in the intravenous administration of a 10% solution of glucose with potassium, 5% solution of glucose with vitamin C, vitamins of group B i / m, a solution of sulfocamphocaine i / m, the operation was performed on March 18, 1997: laparotomy, extended gastrectomy . During the audit: the tumor is infiltrative-ulcerative, circularly narrows the antrum, infiltration along the lesser curvature in the region of the angle of the stomach, lymph nodes of the 1st and 3rd lymph outflow collectors are enlarged, with cytological examination of which metastatic lesions were obtained. After mobilization of the stomach with ligaments, omentum and lymphadenectomy in the volume of R3, gastrectomy was performed, with the formation of esophagoenteroanastomosis according to the proposed method. The initial loop of the jejunum was carried out in the mesentery window of the transverse colon. 30 cm from the tracheal ligament, provisional serous-muscular sutures were applied. U-shaped was fixed to the posterior wall of the esophagus, lateral - along its edges and taken to the "holders". Similarly, a distal row of sutures was formed - behind the muscular roller of the esophagus. The wall of the esophagus is thinned, so the "dirty" row of sutures is imposed with technical difficulties. By distal holders with the help of half-kisets, the anterior wall of the intestine is pulled upwards, with two skid seams behind the muscular bead of the esophagus, the anastomosis invagination into the intestinal lumen was completed. The threads are cut, two half-sets with the help of proximal holders additionally covered the front wall of the anastomosis. With the right holder, the leading loop of the intestine is wrapped from left to right, while it tightly squeezed the esophagus. A 3.0 cm suture was placed below the anastomosis, matching the mesenteric edges of the intestine with the mesentery, and then the mesenteric edges of the intestine were fixed with two sutures. Enteroenteroanastomosis was applied according to the usual method and fixed in the window of the mesentery of the transverse colon with separate sutures. The operation was completed by placing silicone vacuum drains through contra-holes in the hypochondria to the zone of esophagoenteroanastomosis.

 In the postoperative period, the patient received infusion therapy, blood transfusion, albumin, kefzol i / v, vitamins, sulfocamphocaine i / m. Peristalsis normalized on the 6th day. Having performed an anastomosis fluoroscopy, on the 7th day after the operation they were allowed to consume liquid food. They were discharged for outpatient treatment on the 13th day after the operation. During the control examination after 3 months in the outpatient department: no complaints, ate portions in the amount of 250-300 ml, recovered by 3.0 kg. During the control fluoroscopy, the anastomosis functioned satisfactorily, reflux of barium suspension into the esophagus was not observed.

 The analysis of the operational activities of the department from 1993 to 1997. It was found that during this period the proposed type of esophagoenteroanastomosis was used in 299 patients. Of these, 10 people died (3%), and 2 patients died from insolvency. Anastomosis failure was recorded in 5 cases, which amounted to 1.06%, and it should be noted that over the past 3 years anastomosis failure was not recorded. In 3 cases of anastomotic insufficiency, patients were cured without additional surgical intervention, since adequate drainage was achieved due to vacuum drainage delivered during the operation, and peritonitis was local due to the lack of connections between the anastomosis zone and the remaining parts of the abdominal cavity. One of the cases of insolvency leading to death was recorded in the area of enteroenteroanastomosis. In another case - a specific source of diffuse peritonitis was not detected - the operation was performed in a "wet" stomach, tumor invasion was through all layers of the stomach. Four patients died from acute cardiovascular failure, two from pulmonary heart failure.

 When analyzing long-term results, the fact of extremely rare complaints of reflux esophagitis and a satisfactory general condition of patients is noteworthy. In total, there were 217 operated patients under observation in the dispensary (the rest were irregular or not treated at all). The observed contingent of patients revealed the following complications. Reflux esophagitis - 15 (6.8%), and it should be noted that only two patients needed medical treatment in a hospital - in other cases, correcting the diet, and using decoctions of herbs (chamomile and calendula) was enough. Mild dumping syndrome was noted in 8 patients, was stopped by the introduction of antispasmodics, vitamin therapy, a temporary refusal of liquid food. Two patients had symptoms of adhesive disease. The average length of stay of a patient in a bed was 28.0 days.

 Considering the requirements put forward to esophagoenteroanastomosis - simplicity, reliability, physiology - we believe that the proposed method fully corresponds to them. Based on the fact that the severity of the condition of cancer patients, more often their elderly age and concomitant pathology, do not always allow for the recent gastroplasty after total gastrectomy. We believe that the proposed method for applying esophagoenteroanastomosis is quite modern and should be used in practice.

Claims (1)

 A method for the formation of an esophageal-intestinal anastomosis after gastrectomy for gastric cancer, including dissection of the muscular membrane of the esophagus to the submucosal layer and the formation of a “dirty” row of sutures through all layers of the intestinal wall with a needle at the base of the mucous membrane, as well as the submucous and mucous layers of the esophagus, characterized in that when applying a “clean” row of seams, the back wall is hemmed with one U-shaped seam, the front one with half-sutures, using one thread from the side holders, and two suture seams, tightening and twisting the wall of the intestine to the front wall of the esophagus, impose a purse string suture on the mesenteric edges of the loops of the intestine with the mesentery.