RU2148958C1 - Surgical method for treating the cases of reflux esophagitis in performing jejunoplastic reconstruction after gastrectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves transecting adducting intestine 3 cm proximal relative to the gastroesophageal anastomosis. Muscular tunic of the esophagus is separated and muscular constrictor is formed. A piece of seromuscular coat of 25x30 mm is removed from the jejunotransplant. Invaginating valve is formed. Muscular constrictor edges are sutured to the edges of the mucosubmucous platform of the jejunotransplant. Submucous substratum excess of the esophagus and jejunum is placed into the lumen of the jejunum. The abducting intestine is transected 15-16 cm distal from the gastroesophageal anastomosis. Interintestinal anastomosis is formed. EFFECT: improved reflux-preventing properties of the esophagojejunal anastomosis. 6 dwg

Description

 The invention relates to medicine, surgery, and specifically to methods for surgical treatment of reflux esophagitis with reconstructive eunogastroplasty after gastrectomy.

 Known methods for surgical treatment of reflux esophagitis are, as a rule, the translation of an operation such as Billroth II in Roux. However, despite performing an operation such as Roux, the frequency of reflux esophagitis decreases slightly. However, to date, among the causes of mortality after gastrectomy, the failure of the esophageal-intestinal anastomosis sutures (50-85%) is in the first place [4], postoperative reflux esophagitis occurs in 8.7-56.6% [2.5], and , according to some authors, reaches 96% [3].

 At the same time, any complication of the methodology for the formation of esophageojunoanastomosis does not contribute to the wider introduction of the latter into clinical practice.

 Closest to the proposed is the method described by E.I. and A.E. Zakharov, 1970 [1], which is as follows. After performing a laparotomy and revision, they begin the reconstructive stage of the operation, which consists in disconnecting the adducting gut in the immediate vicinity of the eunoeunoanastomosis, then the abduction loop is pulled to the duodenal stump and the eunoduodenostomy is formed, end-to-end or end-to-end. After this, an intestinal anastomosis is applied. Thus, due to the restoration of the transduodenal passage of food, the casting of duodenal contents into the esophagus is prevented. However, this method is not always effective in the treatment of reflux esophagitis, because there is no closure mechanism in the area of esophageoyunoanastomosis.

 A new technical result - increasing the effectiveness of treatment by enhancing the areflux properties of esophageoejunoanastomosis, is achieved by using a new method of surgical treatment of reflux esophagitis in reconstructive eunogastroplasty after gastrectomy, consisting of an upper median laparotomy, cutting a graft from the abdominal musculoskeletal artery, and from the submucous membrane of the esophagus, which is turned up and stitched to the muscle the ovule of the esophagus, forming muscle sphincter, on the anti-mesenteric part of the junotransplant in the immediate vicinity of the esophageojunoanastomosis, the serous-muscular membrane 25 × 30 mm in size is removed, after which the invagination valve is formed by suturing the lower edge of the anterior semicircle of the muscular pulp of the esophagus and the upper edge of the sero-serous of the transplant, then the anterior sero-muscular nodal sutures passing through the lower edge of the muscle pulp of the esophagus and the lower edge of the serous-muscular olochki formed muco-submucosal areas, completing the formation of ezofagoeyunoanastomoza, knotted joints, plunging excess submucosa of the esophagus and the jejunum in the final clearance.

 The method is as follows. From the upper mid-access, an audit and mobilization of the discharge and adduction loops of the jejunum is performed. The adducting intestine is cut off 3 cm proximal to the esophageal-intestinal anastomosis, its distal end is sutured tightly, and the proximal end is transferred below the mesocolon. The discharge loop of the intestine intersects 14-16 cm distal to the esophageal-intestinal anastomosis. The duodenal stump is mobilized. The invagination-valvular jeunoduodenoanastomosis is superimposed. In the abdominal esophagus directly at the esophagoejunoanastomosis, the muscular membrane of the esophagus is circularly dissected, the latter, contracting, exposes the submucosal base for 10 mm (Fig. 1). The assistant grabs the edge of the muscle with tweezers and lifts it. At the same time, the surgeon dissects the connective tissue fibers between the muscle and submucosal layers of the esophagus wall. The muscular membrane of the esophagus, separated over a length of 10-12 mm, is wrapped up and hemmed in the state of moderate tension to the longitudinal muscle layer of the esophagus along the edge (Fig. 2). At the proximal end of the formed graft, a section of the serous-muscular membrane 25 × 30 mm in size is cut out, cut off and removed. At the same time, most of the site is located in front of the esophagoejunoanastomosis (Fig. 3). An invagination valve is formed. The posterior 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 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. 4). When tying sutures, the excess of the submucosal-mucous membrane of the esophagus and jejunum is immersed in the lumen of the latter, which is the basis of the valve being formed (Fig. 5). In order to prevent disinvagination of the valve in the area of the corners of the anastomosis, 2 sero-muscular sutures are placed on each side (Fig. 6). The operation is completed by conducting a microprobe into the jejunum below the anastomotic zone 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, 2 patients aged 43 and 45 years were operated on. Operations were performed regarding reflux esophagitis III tbsp. and severe dumping syndrome. Complications in the early postoperative period were not observed in patients.

 Patients in the early and long-term postoperative period underwent a set of examinations, including laboratory and instrumental methods of research.

 The results of an endoscopic examination of patients 2 months after surgery: the mucous membrane of the esophagus is not changed, esophageojunoanastomosis is closed, freely passable, with air insufflation, it opens up to 12-14 mm Crescent-shaped invagination valve. The mucosa along the suture line of the anastomosis is not changed. Transplant with a length of 14 to 16 cm, mucous membrane of normal color. There is light mucus in the lumen. Anastomosis with the duodenum (duodenum) end to end, closed, freely passable, the mucosa in the valve area is not changed, below the valve in the lumen of the duodenum is bile. The invagination valve peristals (for 30 s - 6 contractions).

 An X-ray examination after two months: the contrast mass passes freely through the esophagus, the anastomosis peristalsis, opening up to 20 mm, passing barium into the graft in portions. The esophageal mucosa above the valve is not changed. A conical-shaped transplant with a gas bubble in the proximal region, which indicates a good areflux function of esophageojejunoanastomosis. 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. After an hour and a half in the graft there are traces of contrasting mass, the main part of it in the loops of the jejunum.

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

 Clinical example. Patient B., 43 years old, was admitted to the hospital on February 19, 1997 with a diagnosis of a condition after gastrectomy for a cardiac gastric ulcer from 1996. Complication: reflux esophagitis III tbsp. Dumping syndrome of moderate severity.

 Upon admission, complains of weakness, periodic dizziness, increased weakness and dizziness after eating, especially starchy foods. Constant regurgitation of food, heartburn, hypersalivation. The chair is unstable up to 10 times a day. I lost 10-12 kg. Burning pains behind the sternum. From the anamnesis: on June 19, 1996, he underwent gastrectomy for a callous ulcer of the cardial section of the stomach with the formation of an esophageal-intestinal anastomosis according to Gilyarovich. After the operation, the condition worsened despite the ongoing courses of rehabilitation therapy. Entered for reconstructive surgery. General condition is relatively satisfactory. The skin and mucous membranes are pale in color. On the part of internal organs - age-related changes.

 FGDS from 02.21.97, the upper third of the esophagus is not changed. In the middle and lower third of the esophagus there are many longitudinal erosions with a touch of fibrin. Anastomosis 38 cm from incisors of irregular polygonal shape, gapes, freely pass. The mucosa in the area of the anastomosis is hyperemic, there are no mucosal defects, infiltration is not determined. Behind the anastomosis is a loop of the jejunum. In the lumen of the intestine is fresh bile, which is thrown into the esophagus.

 Conclusion: the condition after gastrectomy, esophagoejunoanastomosis with anastomositis, erosive esophagitis III tbsp.

 X-ray of the stomach from 02.22.97, the Esophagus is freely passable, in the lower third there are signs of esophagitis III tbsp. Esophagogoejunoanastomosis end to side in the abdominal cavity opens up to 2 cm, passes thick barium freely, gapes. In vertical and horizontal position, there is a throwing of contrast medium from the intestine into the esophagus. The abducting intestine has a mucosal relief, which corresponds to the relief of the small intestine, live peristalsis. The passage of barium through the intestines is quick, without delay. After 1 h, all barium in the distal small intestine. Conclusion: condition after gastrectomy, intestinal dumping.

 After the preoperative preparation, 02/28/97, the reconstructive surgery was performed: the formation of the areflux valve in the area of the esophageal-intestinal anastomosis, reduction, resection of the adducting loop of the intestine. Drainage of the subhepatic and subphrenic spaces. Anesthesia: anesthesia, access: upper middle. Severe cicatricial adhesions, especially in the subhepatic and subphrenic spaces. With technical difficulties, the leading and abducting loop of the intestine was isolated. The esophageal-intestinal anastomosis and part of the lower thoracic esophagus were isolated from the fusion and partially from the posterior mediastinum. The esophageal-intestinal anastomosis is formed by the type of end to side. The outlet loop of the intestine up to 18 cm long, the leading one - 17 cm. A resection of the lead bowel loop was made, not reaching the esophageal-intestinal anastomosis of 3 cm. The end of the intestine is sutured with a 2-row suture. Immediately above the suture line of the esophageal-intestinal anastomosis, the muscular membrane of the esophagus was cut, followed by its separation to a width of 12 mm. Formed by pulp of the esophagus. A valve is formed from the mucous membrane of the esophagus and the intestinal outlet loop. The duodenal stump is highlighted for a length of 35 mm. An invagination-valvular jejunoduodenoanastomosis with a 28 mm valve was imposed. An inter-intestinal anastomosis is applied end-to-end with a 2-row suture. The window into the mesocolon is stitched. Conducted probes. Drainage of the subhepatic and subphrenic spaces. Stitches on the wound.

 The course of the early postoperative period is smooth. Suture healing by primary intention. The probe from the transplant was removed on the 5th day, the microprobe was removed on the 6th day after the operation.

 FGDS from 03.19.97 (the 19th day). Esophageal mucosa of normal color. Anastomosis 41 cm from the incisors, closed, freely passable, peristalsis. Mucous along the line of the anastomosis without signs of inflammation. Below the anastomosis is a loop of the jejunum up to 11 cm, in the lumen there is mucus, no bile. Invaginative jejunoduodenostomy with valve, freely passable, duodenal mucosa not changed. Foamy bile in the lumen.

 Conclusion: the state after gastrectomy, eunogastroplasty, esophageal and eunoduodenoanastomosis with normal function.

 Examined 1 year after surgery. He makes no complaints, does not comply with the diet, stool 1-2 times a day, gained 2 kg in weight.

 Endoscopic examination of February 19, 1998 (1 year after surgery). The mucous membrane of the esophagus is not changed, esophageojejunoanastomosis closed, freely pass. The mucosa in the anastomosis is not changed. The invagination valve in the form of a lunate fold, peristalsis. The graft is up to 15 cm long, the mucosa is pale pink. There is light mucus in the lumen. Anastomosis with duodenum is end-to-end, closed, freely passable, the mucosa in the valve area is not changed, below the valve in the lumen of the duodenum, bile. The invagination valve peristals.

 Conclusion: a condition after gastrectomy with ejunoplasty. Invagination valve.

 X-ray from 02/23/98. Time after surgery 1 year. The esophagus is not changed. Esophagogoyunoanastomosis above the diaphragm, pronounced closure function, barium passes in small portions, rhythmically. The maximum disclosure of the anastomosis is up to 15 mm. Peristalsis and transplant tone are satisfactory. The latter is in the form of a tube. Folds are not changed. Eunoduodenoanastomosis 10 mm wide opens rhythmically. Primary evacuation time 2 min. When tight filling evacuation unchanged. The peristalsis of the graft is pendulum-like, translational. Peristalsis of the duodenum is not impaired. There are no refluxes while standing and lying (in the Trendelenburg position) to the graft and esophagus. After 1 h in the graft up to 30% of the contrast mass. Receipt of contrast in the proximal colon after 6 hours from the start of the study, after 24 hours there was stool with barium.

 Thus, the proposed method for the treatment of reflux esophagitis in the operation of reconstructive eunogastroplasty after gastrectomy allows the treatment of reflux esophagitis. The formation of pulp on the esophagus forms a protection against increased pressure, the valve from the submucosal mucous membrane of the esophagus and intestine with an increase in intra-abdominal pressure blocks the lumen of the esophagus at the level of the esophageal-intestinal anastomosis, prevents the reflux of intestinal contents into the esophagus, and prevents the development of reflux esophagitis. The size of the site of the removed serous-muscular membrane of the jejunum 25 • 30 mm, contributes to the creation of the valve necessary to close the lumen of the esophagus in the pulp.

List of references
1. Zakharov E.I., Zakharov A.E. Eunogastroplasty in diseases of the operated stomach.- M .: Medicine, 1970, 232 p.

 2. Krolevets I.P., Demin D.I. Invagination areflux esophageal anastomosis in gastrectomy and proximal resection. - Surgery. - 1994, N 3, p. 13-16.

 3. Kuzin N.M., Shkrob O.S., Uspensky L.V., Harnas S.S. The choice of the optimal variant of the reconstructive stage of gastrectomy. - Surgery. - 1992, N 3, p. 40-43.

 4. Makhov G.A., Ignatov G.I., Yudin E.V. A new method of esophagoenteroanastomosis in gastrectomy. - Vestn. chir. them. I.I. Grekova. - 1996, N 2, p. 86 and 87.

 5. Tamulevichute D.I., Vitenas A.M. Diseases of the esophagus and cardia.- M .: Medicine, 1986, 224 p.

Claims (1)

 A method for the treatment of reflux esophagitis during reconstructive eunogastroplasty surgery after gastrectomy, including an upper median laparotomy, characterized in that the adducting intestine is crossed 3 cm proximal to the esophageal-intestinal anastomosis with suturing of the distal end of the intestine tightly, the muscular membrane is peeled and the intestine is exfoliated from underneath hemmed to the muscular membrane of the esophagus, forming muscle pulp, on the anti-mesenteric part of the junior graft in the immediate vicinity of the esophagoejunoanast mosa remove the serous-muscular membrane with a size of 25 x 30 mm, after which an invagination valve is formed by stitching the lower edge of the formed muscle pulp of the esophagus and the upper edge of the serous-muscular membrane of the mucous-submucosal area of the transplant when applying the posterior row of serous-muscular sutures, as well as by stitching the lower edge of the muscle pulp of the esophagus and the lower edge of the serous-muscular membrane of the formed mucous-submucosal area when applying the front row of serous-muscular sutures, when tying sutures zhayut excess submucosa of the esophagus and the jejunum into the lumen of the latter, then cross the abductor intestine on 15 - 16 cm distal esophageal-intestinal anastomosis, impose intestinal anastomosis.

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